HomeMy WebLinkAboutARBUC_APP_W9.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATION
Complete the tillable 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:-e.3 rr
/^cnry'Arl. ^Name of Business Owner(s):
-Au biir n
City of Auburn Business License number: CpO\ l"/b
n lA
Business Address:
Expiration Date of Business License:
)
Contact Person Name and Title:ntorygr
Contact Person E-mail:■':>t
Contact Person Phone:
(Optional) Is this business 51% minority-owned or women-owned (Y/N)
Please initial each to confirm:
10 or fewer employees
^ A for profit business in the City of Auburn established prior to January 1, 2020
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BUS-27486
12/31/2020
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Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
Business was adversely impacted by mandatory 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:
l 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.
l The Grantee affirms that residents, customers and/or employees are not
discriminated against due to race, creed, color, religion, sex, national origin, or
disability.
l 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discrimination law or policy, this Agreement may be rescinded, cancelled, or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.
l In no event shall the City's financial responsibility exceed the approved amount,
set forth below.
l The Grantee is responsible for any and all costs or liability arising from the
Grantee's failure to so comply with applicable law.
l 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.
l 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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l 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.
l 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.
l 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).
l I am the duly authorized representative of the entity named above and can bind
the entity to the terms of this Agreement.
l 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.
l I have Provided a current IRS W-9 with my signed application
Date: \^\ ?J)2dApplicant Signature:
By signing this document, I attest that no event has occurred and no condition exists that is ijkely t(/ result i
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
in
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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8/26/2020
X
-9 Request for Taxpayer
Identification Number and Certification
Give Form to the
requester. Do not
send to the IRS.
Form
(Rev. October 2018)
Department of the TreasuryInternal Revenue Ser/ice ► Go to www.irs.govlFormW9 for instructions and the latest information.
1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.
2 Business name/disregarded entity name, if different from aboveL 'fe>Cc>
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of thefollowing seven boxes.
Individual/sole proprietor or d C Corporation EH S Corporation EH Partnership
single-member LLC
□ Trust/estate
CO 4 Exemptions (codes apply only tocertain entities, not individuals: see
instructions on page 3):
oU)caaco
. in Exempt payee code (if any)IV ca o I I Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ►
Note; Check the appropriate box in the line above for the tax classification of the single-member owner. Do not checkLLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC isanother LLC that is not disregarded from the owner for U.S. federal tax purposes. OthenA/ise, a single-member LLC thatis disregarded from the owner should check the appropriate box for the tax classification of its owner.
I I Other (see instructions) ►
*=o3O Exemption from FATCA reporting
code (if any)1 ii o
o (Applies fo accounts maintained outside the U.S.)Da 5 Address (number, street, and apt.
(3 0 I ^ n (ajZ. . ir
or suite no.) See instructions.Requester’s name and address (optional)CO
Q)0)CO
6 City, state, and ZIP code
Ut-kLg -r^pp-5 UJfr
7 List account number(s) here (optional)
Parti Taxpayer Identification Number (TIN)
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoidbackup withholding. For individuals, this is generally your social security number (SSN), However, for a
resident alien, sole proprietor, or disregarded entity, see the instructions for Part i, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get aTIN, later.
Social security number
b 3 ^ - 7 P ^
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 ior guidelines on whose number to enter.
Employer identification number
Part II 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 RevenueService (IRS) 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 amno longer subject to backup withholding; and
3.1 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.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding becauseyou 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 (IRA), and generally, paymentsother than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
SignHere Signature of
U.S. person ►Date*-
General Instructions ● Form 1099-DIV (dividends, including those from stocks or mutualfunds)
● Form 1099-MISC (various types of income, prizes, awards, or grossproceeds)
● 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), 1098-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 (including a residentalien), to provide your correct TIN.
tf you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,later.
Section references are to the Internal Revenue Code unless otherwisenoted.
Future developments. For the latest information about developmentsrelated 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 aninformation return with the IRS must obtain your correct taxpayeridentification number (TIN) which may be your social security number(SSN), individual taxpayer identification number (ITIN), adoptiontaxpayer 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 l imited to, the following.
● Form 1099-INT (interest earned or paid)
Form W-9 (Rev. 10-2018)Cat. No. 10231X
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