HomeMy WebLinkAboutAVEDENT_APP_W9.pdf,.,. W'9
(Rev. October 2018)
Depahenl of lhe Treasury
lnternal Revenue Service
Request for Taxpayer
ldentification Number and Certification
> Go to www.r1.s.gov lFormwg lor insLtlclions and the latest intormation.
Give Form to the
requester. Do not
send to the lRS.
1 Name (as shown on yolr
Signeture of
U.S. person >
do not leave this line
o
qo
l^i ALIA AND SAI YA,s /'rqsi A pLLC
name/disregarded entity name,
7 List account number(s) here
4 Exemptions (cocles appiy only io
certain eniities not ndivdualsl see
insvuctions on page 3):
ExenrPt Payee code (il any)
Exemption lrom FATCA GPorting
code (lr any)
(awttds to a.caunts Ntntstne't autslde the u s )
E"t* y., Tlt{ |n th"appr.priate box The TtN provided must match the name given on ine 1 to avold
bacf<r;p witnnofaing. Fo; individuals, this is generally your social security numbef ISSN) H9*9,u, "'l fo' u
res dent alien, sol+roprietor, or disregardJd entity, iee the rnstructions for Part.l later' For other
"ntiti"", ii i" Vor|. "ti'ployer identificati;n number (ElN) lf you do not have a number, see How to get a
General Instructions
Section references are to the Internal Revenue Code unless otherwlse
noted.
Future develoDments. For the latest nrormatlon about developnents
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go lo www.irs.govlFormwg
Purpose of Form
An lndividual or entity (Form W-g requester) who is required to file an
informatlon return wlth the IBS must obtain your correct taxpayer
identification number CflN) which may be your social security number
(SSN), individual taxpayer ldentiflcation number {lTlN), adoption
iaxpayer identification number (ATIN), or employer identification number
lElN;, io report on an information return the amount paid to you, or other
amount reportable on an information retum Examples of information
retlrrns inctude. but are not limited to, the following
. Form 1099lNT (lnterest earned or paid)
Date >O I;E /2
. Form 1099-DlV (dividends, including those from'stocks or mutual
funds)
. Form 1099-[.4lSC (various types of ]ncome, prizes' awards, or gross
proceeds)
. Form 1099-8 (stock or mutual fund sales and certain other
transactions by brokers)
. Form 1099-5 {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)'
10S8-T (tuition)
. Form 1099-C (canceled debt)
. Form 1099-A (acquisttion oI abanoonment of secured proPe'ty)
Use Form W-9 only if you are a U S person (including a resident
alien), to provide your correct TlN.
lf vou do not retum Form W'9 to the rcquester with a TlN, you might
be;ubiect to backup wlthholdlng. See What is backup withhoLdlng,
later-
flN, later.
Note; lf the account is in more than one name. see the instructions for line 1- AIso see What Name and
Numbet To Give the Requesterfor guidelines on whose number to enter'
lJnder penaltres of perlury, I certify lhat:
1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be lssued to me); ano
2. I am not sublect to backup withhotctng because:ia1-l am exempt from backup wrthholding, or (b) | have not been not fied by the Internal Bevenue
service {tRSi that I am "uoj""t to oa"r,Li-i[iiiidilg u" "r"ruit or
"
failure to report all inierest or dividends, or (c) the lRs has notified me that I am
no longer subject to backup withholding; and
3. I am a U.S. citzen orother 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 ls correct'
certification inslructions. you musr cross out item 2 above if you have been notifed by the IBS that you are currently subiect to backup withholding because
you have failed to report att interest ano orviJenO" onloui t"" ]'6trrn. For real estate iransactions, itern2 does not apply For mortgage interest paid'
acquisition or abandonment ot secur"o profJrtf, caniettation of oeot, contributions to an individual retirement arrangement (lRA), and generally, payments
otherthan interest and divrdends, you are;;i;iui."J t. sgn irt" ""tiification,
but you must provide your correct TlN. see the insiructions for Part ll' later'
Here vAJt
3 C heck app.opriate box for federal tax c lassification of the peGon whose name is entered on line 1 . Check only one ol the
folowing seven boxes.
d lnoiv arlaysote proprietor or I c co,potaton ! s corporation n eannersnlp I Trusvestare
single-member LLC
fl Lim;teo tiaoitity "o|npany. Enter the tax classificaton (c=c corporatiof, s=s corporation, P= Partnership) > _
Note: check the appropriate box tn the li.e above for the tax classification of the single_member owner- Do not check
LLC I the LLC is classiiied as a singte-membef LLC that is disregarded irom the owner unless the owner of the LLC is
anotherLLcthatisnotdisregardedflomtheownerforU'S'federa|taxpurposes'otherwise'asing|e-memberLLCth
is disreqarded from the ownel sho!ld check the appropriate box for ihe tax classiflcation oi ts ownef
r. stfeet. and aPt- or sulte'>2 <i. ^rct,e '-\" SL Ne
^"\guRr.t ur, A .? &C-D')-
Cat No 10231X (Rev 10-2018)
DocuSign Envelope ID: C0342786-9D51-4ABB-8CFE-26840D39706F
Applicant shall defend and indemnify the City and its employees from and against
any claim, injury, Iiability, 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 eve nt.
The representations made by applicant in this Application are materialterms 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
r 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
CoV|DreIatedimpactsandneededtomitjgatefinancialdamagestoyour
business.. I have Provided a current IRS W-9 with my signed application
o.,,u ( , f - t,,it( lt,'
Appficantsignature: N;\il"" )"-"2"'tAz--''" 931s: /0/"/l /'< Q
BV signing this document, I atte{t that no event has occurred and no condition exists that i, tit 6ty to 'friili-
the debarment or suspension of the business from contracting with the u.S Government or anv agency or
instrumentality thereof, and the business is not now and has not been subiect to any such debarment or
suspension.
TO BE COMPLETED BY CITY STAFF
Grant Application Granted? Yes ! No I
lf no, provide reason for denial:
lf no, has notification been sent to applicant? Yes E No E
Grant Payment Date:
City Representative Signatu re:Date:
DocuSign Envelope ID: C0342786-9D51-4ABB-8CFE-26840D39706F
10/30/2020
X
}}Business has a physicalpresence (address) located within a commercial zone
within the Citv of Auburn. (Home based businesses do not qualify)'
) \, gutin.ss was adversely impacted by mandatory and/or voluntary business
closures directlv related to the public health response related to COVID-19
)\Businessingoodstanding(including:currentCityofAuburnbusinesslicense;
current on all State and regulatory requirements; not facing pending litigation or
legal action, including Shoreline code enforcement)
Bymysignaturebelow,IhavereadandunderstandtheSmalIBusinessAssistance
GrantProgram.Imakethefollowingrepresentationsandacknowledgeagreementto
the following terms and conditions:
The Grantee shall comply with all applicable federal, state' and local non-
discriminationIawsand/orpolicies,including,butnotIimitedto,theAmericans
With DisabiIities 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
d isa b il ity.
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.
InnoeventshalltheCity,sfinanciaIresponsibiIityexceedtheapprovedamount,
set forth below,
TheGranteeisresponsibleforanyandaIlcostsorIiabiIityarisingfromthe
Grantee's failure to so comply with applicable law'
I bear full responsibility and understand that the Grant funds may be taxable
income;pIeaseconsuItwithyourfinancialadvisorforguidance.AlO99wiIlbe
issued to all grant recipients, as required by the lRS, no later than January 31'
2021.
There is no agency, employment, joint venture or other such relationship
createdbVvirtueofawardofthegrant.TheCitydoesnotendorsethespecific
busrness.
DocuSign Envelope ID: C0342786-9D51-4ABB-8CFE-26840D39706F
SMALL 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
l^JALIA A^rD SAtur hsrMfA PLuc-
Name of eusiH: Aug.rF,NJ A" eruu a )g*Znt-,
Name of Business owner(s): a^ O
'
O a, t At u/ s ftvA
Business Add ress:A 'lt;a-b2-
city of Auburn Business License number: L'c 3o I o 1 %O
A I ,n 1 I r r ^ 1 I
Expiration Date of Business License: tl \YLU- t \' ) du ^ |
I
contact Person Name and Title: -bR Dl P f/ -SAlvAS fA?A I O-ona4- lvtat+{rt,
contact Person E-mail: d rd i bb, S d q "n '- I co 4
contactPersonPhone: +Lt- 7>3 - q)qL (L)
LS\- 89'1- 36 8'D (tzil j i r ,l
(optionaf ) ls this business 51% minority-owned or women-owned(Ylt()-+- M raanrV
tt /lv.,{1,[ d,..lr)
Please initial each to confirm:
\.9. zs or fewer employees
'D \ o for profit business in the City of Auburn established
,L cJl vJ zrywz'-tt- \r.+*l(
aP<-.'al--21,'
prior to January 1,,2020
'3.d S t NE d.ubrrn ql
DocuSign Envelope ID: C0342786-9D51-4ABB-8CFE-26840D39706F