HomeMy WebLinkAboutANTOJ_APP_W9.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATION
Complete the fillable application in its entirety. Print the completed application,
sign and date and email, along with a copy of your W-9, to: OED2@auburnwa.gov.
Applications can also be mailed to the following:
City of Auburn
Attn: Office of Economic Development
25 W Main
Auburn, WA 98001
TO BE COMPLETED BY APPLICANT
N f B . ANTOJITOS MICHALISCO, LLC ame o usiness: _____________ _
. FRANCISCO CHAVEZ Name of Business Owner(s): _________ _
. dd 801 C ST SW, AUBURN, WA 98002 Business A ress: -------------
. f b B . L' b 604-026-802 City o Au urn us1ness 1cense num er: ______ _
Expiration Date of Business License: _______ _
Contact Person Name and Title: Fl DELIA ALAVEZ ---------
•
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PNWBOOKS253@GMAIL.COM Contact Person E-ma, : ------------
Contact Person Phone: 253-353-0299
(Optional) Is this business 51% minority-owned or women-owned (V /N) Y __ _
Please initial each to confirm:
FC 10 or fewer employees
FC A for profit business in the City of Auburn established prior to January 1, 2020
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FC Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
FC Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
FC Business in good standing (including: current City of Auburn business license;
current on all State and regulatory requirements; not facing pending litigation or
legal action, including Shoreline code enforcement)
By my signature below, I have read and understand the Small Business Assistance
Grant Program. I make the following representations and acknowledge agreement to
the following terms and conditions:
• The Grantee shall comply with all applicable federal, state, and local non-
discrimination laws and/or policies, including, but not limited to, the Americans
with Disabilities Act, the Civil Rights Act, and the Age Discrimination Act.
• The Grantee affirms that residents, customers and/or employees are not
discriminated against due to race, creed, color, religion, sex, national origin, or
disability.
• In the event of the Grantee's noncompliance or refusal to comply with any non-
discrimination law or policy, this Agreement may be rescinded, cancelled, or
terminated in whole or in part, and the Grantee may be declared ineligible for
further agreements with the City.
• In no event shall the City's financial responsibility exceed the approved amount,
set forth below.
• The Grantee is responsible for any and all costs or liability arising from the
Grantee's failure to so comply with applicable law.
• I bear full responsibility and understand that the Grant funds may be taxable
income; please consult with your financial advisor for guidance. A 1099 will be
issued to all grant recipients, as required by the IRS, no later than January 31,
2021.
• There is no agency, employment, joint venture or other such relationship
created by virtue of award of the grant. The City does not endorse the specific
business.
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• Applicant shall defend and indemnify the City and its employees from and against
any claim, injury, liability, loss, cost and/or expense or damage including all costs
and reasonable attorney's fees, arising from or alleged to arise from the activity
or event.
• The representations made by applicant in this Application are material terms of
the Agreement, as is compliance with Small Business Assistance Grant Program.
The City may cancel this Agreement at any time upon discovery that any of the
information set forth above is inaccurate, that these terms have been violated,
or any provision of the Small Business Assistance Grant Program has been
violated.
• Upon approval of this application, as evidenced by the signature of the City
Representative below, this application becomes a binding contract between the
entity named above and the City of Auburn (Agreement).
• I am the duly authorized representative of the entity named above and can bind
the entity to the terms of this Agreement.
• I attest that the grant funds will be used to reimburse the costs of business
interruption caused by mandated or voluntary closures directly related to public
health directives associated with COVID-19. These funds are specifically for
COVID related impacts and needed to mitigate financial damages to your
business.
• I have Provided a current IRS W-9 with my signed application
Applicant Signature: ~ Date: 07/10/2020
By signing this document, I attestthat nohas occurred and no condition exists that is likely to result in
the debarment or suspension of the business from contracting with the U.S. Government or any agency or
instrumentality thereof, and the business is not now and has not been subject to any such debarment or
suspension.
TO BE COMPLETED BY CITY STAFF
Grant Application Granted? Yes □ No □
If no, provide reason for denial: __________________ _
If no, has notification been sent to applicant? Yes □ No □
Grant Payment Date: ______________________ _
City Representative Signature: ___________ Date: ____ _
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X
7/31/2020
Form W-9 Request for Taxpayer Give Form to the (Rev. October 2018) Identification Number and Certification requester. Do not Department of the ireasury ln1emal Revenue Service ► Go to www.irs.gov/FonnW9 for instructions and the latest information. send to the IRS.
, Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
ANTOJITOS MICHALISCO LLC
2 Business name/disregarded entity name, if different from above
(")
a, 3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the 4 Exemptions (codes apply only to 0, lollow,ng seven boxes. "' certain entities, not individuals; see a. instructions on page 3): C 0 0 C Corporation D S Corporation D Partnership D TrusVestate 0 Individual/sole proprietor or
• O'I single-member LLC Q) C Exempt payee code [rf any) ii D Limtted liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Par1nership) ► u ... :, 0 ... Note_: Check th_e appropriate box_ in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reporting 'E .; LLC rf the LLC rs classrfied as a single-member LLC that is disregarded from the owner unless the owner of the LLC is -C code (H any) .,__ another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that ~u :i: 1s disregarded from the owner should check the appropriate box for the tax classHication of its owner. u □ Other (see instructions) ► ~pplies to accounts mainlained outside the U.S.) & 1/) 5 Address (number, street, and apt. or sutte no.) See instructions. Requester's name and address (optional) a, 801 CST SW Cl)
Cl)
6 City, state, and ZIP code
AUBURN, WA 98002
7 List account number{s) here {optional)
1111~1 i■■ Taxpayer Identification Number (TIN)
I Social security number I Enter you'. TIN in_ the app_ropriate box. The TIN provided must match the name given on line 1 to avoid backup w1thhold1ng. For 1nd1v1duals, this 1s generally your social secunty number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the instructions tor Part I, later. For other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN, later.
[TI] -[I] -I I I I I
or
Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to· enter.
! Employer identification number
81 -3512128
Certification
Under penalties of perjury, I certify that:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service OAS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and
3. I am a U.S. citizen or other U.S. person (defined below); and
4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct
Certificatlon lnstructlon&. You must cross out item 2 above if you have been notified by the IRS that you are curren11y subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement ORA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part 11, later.
Sign
Here
Slgnature of
U.S. person ►
General Instructions
Section references are to the Internal Revenue Code unless otherwise
noted.
Future developments. For the latest information about developments related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.irs.gov/FormW9.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an information return with the IRS must obtain your correct taxpayer
identification number (TIN) which may be your social security number (SSN), individual taxpayer identification number (ITIN), adoption taxpayer identification number (ATIN), or employer identification number (EIN), to report on an information return the amount paid to you, or other amount reportable on an information return. Examples of information returns Include, but are not limited to, the following.
• Form 1099-INT (Interest earned or paid)
Cal No. 10231X
Date► ( 30 20
• Form 1099-DIV {dividends, including those from stocks or mutual funds)
• Form 1099-MISC (various types of income, prizes, awards, or gross proceeds)
• Form 1099-B (stock or mutual fund sales and certain other
transactions by brokers)
• Form 1099-S (proceeds from real estate transactions)
• Form 1099-K (merchant card and third party network transactions)
• Form 1098 (home mortgage interest), 109&-E (student loan interest),
1098-T (tuition)
• Form 1099-C (canceled debt)
• Form 1099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a U.S. person ~nciuding a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TTN, you might
be subject to backup withholding. See What is backup withholding, later.
Form W-9 (Rev. 10-2018)
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