HomeMy WebLinkAboutCRUZE_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
Name of Business:l-l-<*c-
Name of Business Owner(s):
Business Address:NE
City of Auburn Business License number: ? U 5 -)t1 Z>Q
Expiration Date of Business License: L 4 U f (ZO
_ Contact Person E-mail:
Contact Person Phone:
contact person Name and Titte: #blc yt Cn t7x- L[4F11 0 onuV
,*,
K, L r e-*"_z-u---, 14€ nJ . c-a t4/L
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(Optional) ls this business 51% minority-owned or wom"n-o*n(fuv) X
Please initial each to confirm:
a\ 1o or fewer employeesE\A for profit business in the City of Auburn established prior to January 1.,2020
MFfC
22025
DocuSign Envelope ID: F38BCC9A-8431-4233-A1CB-9B89EEBD51B5
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
Rqpreseltative below, this application becomes a binding contfact 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: gl t Z/>a
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 su.bject to any such debarment or
suspension.
TO BE COMPLETED BY CITY STAFF
Grant Application Granted? Yes tr No tr
lf no, provide reason for denial:
lf no, has notification been sent to applicant? Yes fl No tr
Grant Payment Date:
City Representative Signature :Date:
no event has occurred and no condition exists that is likely to result in
DocuSign Envelope ID: F38BCC9A-8431-4233-A1CB-9B89EEBD51B5
8/26/2020
X
Form
(Rev. C
Deparlr
Internal
w-9
)ctober 201 8)
nent of the Treasury
Revenue Service
Request for Taxpayel
ldentification Number and Certification
Go lo www.irs.govlFormW9 tor instructions and the latest information.
Give Form to the
requester. Do not
send to the lRS.
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.rDCndividual/sole proprieior or' single-member LLC
I CCorporation I scorporation T-'1 - .. T-]_L-l Padnership L-J Trust/estate
3 Check"appropriate box for federat lax clasiification of -the person whose name is entered on line 1 . Check only one of the
following seven boxes. lJ
Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check
LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is
another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC thal
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
! Otner (see instructions) >
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any) _
Exemption from FATCA reporting
code (if any)
' Y":-ilT iT ""i:ry"* fFe'Y f"' 5L Requester's name and address (optional)
6 Crtv. srard:adfficot6 t t 4l4*, n le Va [ (2, t \r rA ?rozr
7 Llst account here (opt onal)
Taxpayer ldentification Number llN
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generaily your social security number (SSN), However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part l, later. For other
entities, it is your employer identification number (ElN). lf you do not have a number, see How to get a
Social security numberMW Etil"Fl
Note: lf 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.
I/N, later
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 noi subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the lnternal Revenue
Service (lRS) that I am subject to backup withholding as a result of a failure to repod 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 ihat I am exempt from FATCA reporting is correct.
Cedification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to repod all interest and dividends on your tax return. For real estate transactions, item 2 does not apply, For modgage interesi paid,
acquisition or abandonment of secured propedy, cancellation of debt, contribut ons to an individual retirement arrangement (lRA), and generally, payments
Sign
Here Date )l7 Zd
General lnstructio
Section references are to the lnternal Revenue Code unless otherwise
n oted.
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 lo www.trs.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 (TlN) which may be your social secunty number
(SSN), rndividual taxpayer identification number (lTlN), adoption
taxpayer identification number (ATIN), or employer identification number
(ElN), to repoft on an information return the amount paid to you, or other
arnount repoftable on an information return. Examples of information
returns include, but are not limited to, the following.
. Form '1 099-lNT (interest earned or paid)
. Form 1099-DlV (dividends, inciuding 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 cerlain other
transactions by brokers)
. Form 1 099-5 (proceeds from real estate transactions)
. Form 1099-K (merchant card and ihird pady network transactions)
. Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
. Form 1099-C (canceled debt)
. Form 1099-4 (acquisition or abandonment of secured propedy)
Use Form W-9 only rf you are a U.S. person (including a resident
alien), to provide your correct TlN.
lf you do not return Form W-9 to the requester with a TlN, you might
be subject to backup withholding. See What rs backup withholding,
later.
Cat. No.10231X rorm W-9 (Rev. 10-2018)
on this line; do not leave ihis I ne blank.
(Applies to accounts maintdned outside the U.S.)
DocuSign Envelope ID: F38BCC9A-8431-4233-A1CB-9B89EEBD51B5
Business has a physical presence (address) located within a commercial zone
within the city of Auburn. (Home based businesses do not qualify).
XS Business was adversely impacted by manda tory and/or voluntary business' closures directly related to the public health response related to COVID-19
-$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:
r 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, nationat origin, or
disability.
o ln 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.. ln no event shall the City's financial responsibility exceed the approved amount,
set forth below.
o The Grantee is responsible for any and all costs or liability arising from the
Grantee's failure to so comply with applicable law.o I bear full responsibility and understand that the Grant funds may be taxable
income; please consult with your financial advisor for guidance. A 1Og9 will be
issued to all grant recipients, as required by the lRS, no later than Janu ary 3L,
202L.
o 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.
DocuSign Envelope ID: F38BCC9A-8431-4233-A1CB-9B89EEBD51B5