HomeMy WebLinkAboutACEACC_APP_W9.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATION
Complete the fillable applicatio n 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:A
Name of Business Owner(s):Pz<d
Business Address: )Ol An+-bvrvrn NvZ
City of Auburn Business License number: BilS - 3Zq1)
Expiration Date of Business License:t) -bt- 7o 22
Contact Person Name and Title:
Contact Person E-mail' booKKe -Ca-rn,i\.G*tI
contact Person Phone: )S 3 qe1 8508
(Optional) ls this business 51% minority-owned or women-owned (Y/N) UY-\
Please initial each to confirm:
I& 25 orfewer employees
eL A for profit business in the City of Auburn established prior to January t,2O2O
L
DocuSign Envelope ID: 033D6D90-0F5D-4D6D-8ABD-A2832A2C7C4D
t,b Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify)'
C&Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to covlD-19
CE Business in good standing (including: current city of Auburn business license;
current on allstate and regulatory requirements; not facing pending litigation or
Iegal 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
d isability.
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discrimination law or policy, this Agreement may be rescinded, cancelled, or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 shallthe 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 lRS, 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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DocuSign Envelope ID: 033D6D90-0F5D-4D6D-8ABD-A2832A2C7C4D
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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 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
violate d.
Upon approval ofthis application, as evidenced by the signature ofthe 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
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Applicant Signature:Date:
By signing this document, I attest that no event has 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 tr No n
lf no, provide reason for denial:
lf no, has notification been sent to applicant? Yes EI No E
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City Representative Signatu re:Date:
Grant Payment Date:
Df;of:,":
DocuSign Envelope ID: 033D6D90-0F5D-4D6D-8ABD-A2832A2C7C4D
10/21/2020
X
w-9 Request for Taxpayer
ldentification Number and Certification
> Go to www.i6.govlFormyllg for instructions and the latest information.
Give Form to the
requester. Do not
send to the lRS.
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(Rev. October 2018)
Department of lhe Treasury
lntemalRevenue Serv ce
1N on your income tax return). Name is required on this I nei do not leave thrs line blank.
2 siness name/disregarded tity
7 List account numbe(s)re (optional)
Taxp ldentification Number IN
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup wthholding. 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 l, later- For other
entities, it is your employer identification number (ElN). lf you do not have a number, see How to get a
I/N, later.
Note: lf the account is in more than one name, see the lnstructions for line 1 . Also see lryhat Name and
NumbetTo Give the Requester for guidelines on whose number to enter.
4 Exemptions (codes appy only to
certain entities, not individualsi see
instructions on page 3):
Ex-.mpt payee code (ii any)
Exemption from FATCA reporling
code (if any)
(Appttes io accenb nzinbineli are'de the u-s-)
Requester's name and address (optonal)
or
Employer identification number
Certification
Under penaltres o'perjury, I certify thar:
1. The number shown on this form is my correct taxpayer ldentiiication number (or I am waiting for a number to be issued to me); and
2. I am not subiect to backup withholding because: (a) I am exempt from backup withhoding, or (b) I have not been noUfied by the lnternal Revenue
Service (lRS) 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.
Certilication 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 Iailed to report all interest and dividends on your tax return. For real estate kansactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (lRA), and generally, payments
other than interest and dividends, you are not iequired to siEn the cedification, but you must provide yoLrr conect TlN. See the instructions for Part ll, later.
Sign
Here Date >to ou
General lnstructions
Section references are to the internal Revenue Code unless otherwise
noted.
Future developments. For the latest nformatlon about developments
related to Form W-9 and its instructions, such as legislation enacted
after they were published, go to www.i,.s.govlFomwg.
Purpose of Form
An individual or entity (Form W-9 requester) who is required to file an
information return wiih the IRS must obtain your correct taxpayer
identification number fflN) which may be your social security number
{SSN), individua taxpayer identification number (lTlN), adoption
taxpayer identification number (ATIN), or employer dentification number
(ElN), 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 folowing.
. Form 1099-lNT (interest earned or pald)
. Form 1099-DlV (dlvidends, including those from stocks or mutual
funds)
. Form 1099-MISC (various types of income, prizes, awards, or gross
proceeds)
. Form 1099-8 (stock or mutual fund sales and ceriain other
transactions bybrokers)
. 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),
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 resident
allen), to provide your correct TlN.
lf you do not rcturn Form W-9 to the requestet with aTlN, you might
be subject to backup withhold/r,9. See What is backup withholding,
lateL
3 Check appropriate box for lederaitax classification of the person whoso name is entered on line 1. Check only one ol the
following seven boxes,
E lndividuai/sole proprietor or E c corporation pS Corooration n Partnership E Trust/estate
single member LLC
! LimiteC tiaUitity company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) >-
Note: Check the appropriate box in the line above forthe tax classification of the single-member owner. Do nol 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 lrom the owner for U.S, federal tax purposes. Otherwise, a single-member LLC
is disregarded from the owner should check the appropriate box forlhe tax classificalion of its owner.
Other(see instructions)>
5 Address (number, street, and apt. or suite no.) See instructions.
a
6City, state, aad
Socialsecuity number lIIl
)lo lr I 1 q ,1 4
Part ll
Signature ot
u-S. person >
Cat. No. 1023'1x Form W-9 (Rev 10 201s)
Part I
lu
DocuSign Envelope ID: 033D6D90-0F5D-4D6D-8ABD-A2832A2C7C4D