HomeMy WebLinkAboutVIZCLIN_APP_W9 (2).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:4r'rL|.ioAN He^/14,a urS;olt cLi Nic
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UirvH ?,Name of Business Owner(s):N q, (L{€{\: /T
Business Address: ?(L 0af LOT C,LLe of r o rrl D?Sr,tJ, ftu,to un/n )W ft 1{Oo I
City of Auburn Business License number: 8W93+Sfg / t, kr(,s# i 04320
Expiration Date of Business License:2c2c
Contact Person Name and Title C (tor"eloieT-
Contact Person E-mail uir.rttrflrua(Lve N Ot o,Aoo. Carvt
AIt+lzz gg3o
(optional) ls this business 51% minority-owned or women-owned ty/N) fl\10
Ptease initial each to confirm:
Urd- 25 or fewer employees
Ud A for profit business in the City of Auburn established prior to January L, ZOZO
t?-l?1 I
I /VUlJ
Contact Person Phone:206*
1
DocuSign Envelope ID: 3B399203-A36E-4AC1-9C48-52B1D6526F87
V,d Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
U, d Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
U, &)Business in good standing (including: current City of Auburn business license;
current on allstate and regulatory requirements; not facing pending litigation or
legal action, including Shoreline code enforcement)
By my signature below, I harre read and understand the Small Business Assistance
Grant Program, I make the fcllo',ving representations and acknowledge agi'eement tc
the following terms and conditrons:
. The Grantee shall comply with all appiicabie federal, state, and local non-
discrimination laws andlor policies, including, but not limited to, the Americans
with Disabilities Act, the Civil RighrsAct, and the Age Discrimination Act'
r The Grantee affirms that residents, customers and/or employees are not
discriminated against due to race, creed, color, reliSion, sex, nationalorigin, or
d isa bility,
r ln the event of the Grantee's noncompliance or refusalto 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discrimination law or policy, this Agreement may be rescinded, cancelled, or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,
r 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 Iiability arisingfrom the
Grantee's failure to so comply with applicable law,
r I bear full responsibility and understand that the Grant funds may be taxable
income; please consult with your financial advisorfor guidance. A 1099 will be
issued lo all grant recipients, as required by the lRS, no later than January 31,
2071,.
r 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: 3B399203-A36E-4AC1-9C48-52B1D6526F87
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a
Applicant shalldefend and indemnifythe City and its employees from and against
any claim, injury, liability, Ioss, cost andlor 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).
lam 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 m y signed application
o
a
a
l I u g /? ozoApplicant Signature:
By signing this document, I
the debarment or suspensi on
Date:
event has occurred and no ccndition exists that is likelyto result in
business from contractlng with the U 5. Governnrent or any agency or
instrumentality thereof, and the business is not now and has not been subject to any such debarment or
suspe nsion.
TO BE COMPLETED BY CITY STAFF
Grant Application Granted? Yes I No I
lf no, provide reason for denial:
lf no, has notification been sent to applicant? Yes tr wo tr
Grant Payment Date:
3
City Representative Signatu re :Date:
DocuSign Envelope ID: 3B399203-A36E-4AC1-9C48-52B1D6526F87
11/9/2020
X
w-g Request for Taxpayer
ldentification Number and Certification
) Go to www.irs.govlFormW9lor instructions and the latest information.
Give Form to the
requester. Do not
send to the lRS.
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exeapt payee code (if any) _
Exemption from FATCA reporting
code (if any)
(Appli6 to a@ounB maintained ouEide the U.S.)
(optional)
Form
(Rev. October 2018)
Department of the Treasury
lnternal Revenue Service
shown on your income tax return)
T^L
on this line; do not leave this line blank.IS
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2 Business name/disregarded entity name, i{ different
account numbe(s)(optional)
ldentification Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on line l to avo d
backup 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 Parl I, later, For other
entities, it is your employer identification number (ElN) lf you do not have a number, see How ta get a
7/N, later.
Note: lf the account is in more than one name, see the lnstructrons for line 1. Also see What Name and
Number To Give the Requester lor guidelines on whose number to enter.
or
Employer identification number
cation
Under penalties of perjury, I certify that:
'1 . The number shown on this form is my correct taxpayer identification number (or I am waitrng for a number to be issued to me); and
2. I am not subject to backup withholding because: (a) I am exempt from backup wthho ding, 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 far ure to repod all nterest or dividends, or (c) the IRS has notlfied 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 reporling is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IFS 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 mortgage interest paid,
acquisition or abandonment to an individual retirement arrangement (lRA), and generally, payments
other than interest and dividends, you are not you must provide your correct TlN. See the instructions for Pad ll, later
Sign
Here
General ln
Section references are to the lnternal 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 lo www.irs.govlFormW9.
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 (llN) which may be your social security number
(SSN), individual taxpayer identification number (lTlN), adoption
taxpayer identification number (ATIN), or employer identification 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 following.
o Form 1099-lNT (interest earned or paid)
0y 2 o2a
o Form 1099-DlV (dividends, 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 certain other
transactions by brokers)
. Form 1099-5 (proceeds from real estate transactions)
. Form 1099-K (merchant card and third party network transactions)
r Form 1098 (home mortgage interest), 1098-E (student loan interest),
1098-T (tuition)
. Form 1099-C (canceled debt)
. Form 1099-A (acquisition or abandonment oi secured property)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provide your correct TlN.
lf you do not retum Form W-9 to the requester with aTlN, you might
be subject to backup withholding. See What is backup withholding,
Iater.
', street, and apt. or suite no.) See
0 LAT C rt CTiott I \)(,
\tJft 9 00
and ZIP code
security number
Part I
8 2 L2l06?3 5
Part ll
ired to sign the certification,
Signature of
U.S. person ilDate t'
Cat. No.10231X rorm W-9 (Rev. 10-2018)
Requester's name
3 Check appropriate box for federal tax classification of the person whose name is entered on line 1 . Check only one of the
following seven boxes.
XI tnoividuallsote proprietor or E C Corporation E S corporation I Partnership f] TrusVestate,/ \ingle-member LLC
[Limiteoliabi|itycompany'EnterthetaxclasSification(C=Ccorporation,S=Scorporation,P=PadnerShip)>=
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 ciassification of its owner.
l-l Otner (see instructions) >
DocuSign Envelope ID: 3B399203-A36E-4AC1-9C48-52B1D6526F87