HomeMy WebLinkAboutIHOP2.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATION
(Round Two - Restauronts, dining & drinking establishments without drive-thru
copabilities only)
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:
Name of Business owner(sl' ,(, €oho-s*,1,1
Business Address:
City of Auburn Business License number:
Expiration Date of Business License: l)
Contact Person Name and Title: R n €tClU rr^or) ,>ilftL"/
,/.t,-n
Contact Person Phone:
(optional) ls this business 5t% minority-owned or women-owned (y/O
Please initial each to confirm:
q-Are a restaurant, dining, or drinking establishment without a drive-thru
YLofor profit business in the City of Auburn established prior to January t, zo2o
Contact Person E-mail: C
DocuSign Envelope ID: 46A68185-0E46-48C2-A36B-C5324DC95C7D
r Applicant shall defend and indemnify the city and its employees from and againstany claim, injury, liability, loss, cost and/or expense or damage including all costsand reasonable attorney's fees, arising from or alleged to ariie from the activityor event.
o The representations made by appticant in this Apptication are material terms ofthe Agreement, as is comptiance with Small Business Assistance Grant program.
The city may cancel this Agreement at any time upon discovery that any of theinformation set forth above is inaccurate, that these terms have been violated,or any provision of the Small Business Assistance Grant program has beenviolated.
o Upon approval of this application, as evidenced by the signature of the CityRepresentative below, this application becomes a binding contract between theentity named above and the city of Auburn (Agreement).r I am the duly authorized representative of the entity named above and can bindthe entity to the terms of this Agreement.r I attest that the grant funds will be used to reimburse the costs of businessinterruption caused by mandated or voluntary closures directly related to publichealth directives associated with CoVID-19. These funds are specifically forcovlD related impacts and needed to mitigate financial damages to your
business.
o I have Provided a current IRS w-g with my signed application
By signing this document, I attest that no eve-nt has occurred rna * condition exists that is likely to result inI[,]:j:[:I il::::i']:i:l[;^,?i:i.u-" rforn contra.cting *i,r, .r," U.s. Government or any asency orvr qrty qStrItLy Iinstrumentality thereof, and the business is not now and has not been subject to any such debarment orsuspension.
TO BE COMPLETED BY CITV STAFF
Grant Application Granted? yes tr No tr
lf no, provide reason for deniat:
lf no, has notification been sent to appricant? yes tr wo tr
Grant Payment Date:
City Representative Signature:Date:
DocuSign Envelope ID: 46A68185-0E46-48C2-A36B-C5324DC95C7D
n/a
X
11/30/2020
g- Business has a physical presence (address) located within a commercial zone
within the city of Auburn. (Home based businesses do not qualify).
K, Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
K Business in good standing (inctuding: 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:
o 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 Disrimination Act.o The Grantee affirms that residents, customers and/or emptoyees are not
discriminated against due to race, creed, color, religion, sex, national 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.o 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 Iiability arising from the
Grantee's failure to so comply with applicable !aw.o 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 Janu ary 3!,
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: 46A68185-0E46-48C2-A36B-C5324DC95C7D
4
1. Check only one of the
n Trusvestate
Give Form to the
requester. Do not
send to the lRS.
4 Exemptions (codes apply only tocenain entities, not individuals: seeinstructions on page g):
Exempt payee code (if any)
Exemption from FATCA reponing
code (if any)
(Appli6 to accounts majntainql Nbide the U.S.)
stocks or mutual
n
c.joo(uo.
o
otroo>'Et olo trlz,6l
G ol:Ela, I
8.tolololol
3 Check approprtate box foifederd, ,i .fufollowing seven boxes.
tr $fltl*Ym$proprietor or ,/c co'oo',tion n s corporation n earrnership
7 List account here (optional)
Under penalties ot perpflTcertify thal
Enter your TIN in tne app
[Ti:l.:lllfl1,:n;:"J.,':,1y'1y?f:.H:i:glilfl'.rl-ir ".:,,r """,,iiv .i,ii#ii3r.rr. However, ror aresident arien, sore-prop,i"to,.. oi Ji","gil""#;ir;:J#ln"""in:l,i,Hil[1];11?:il,I:#i E;,*..".".
t"'. "
ii{l,t',?i;l is vour emprover identiricatiJn "rrn"iiEirv-iir,v", o" "Jinr"J; ;fi.'#i:." e How to set a
Note: lf the account is in more than one name, see the instru.ctions for line 1. Also see what Name andNumber To cive the Requesfer for guiOelines ;n ;hosle number to enter.
'l ' The number shown on this form. is.my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2' I am not subject to backup withholoing oecause: (a) I am exempt from backup withholding, -or (b) | h;;;;oil;en notified by the lnternal RevenueffffiJli:ti::l fL:H';'J |f,fff[U ;,;'fl;id';s "" a r"suit or , t"iru,." iJ,"port arr inieresi-6ii'iiJ.Ct. r") the rRS has notiried me that r am
3. I am a U.S. citizen or other U.S. person (defined below); and
:"*3::i::::i:f:t"J:::: ]ll' 1"'' (ir.anv) indicatins that I am exempt rrom FArcA reportins is co'ect., , r , v^ I Eyut Lt, tg t5 corrgcl.
i[,l!i3Ti:{! ffi; [!$[i:'ffi;JiJtr,';::t?'Ji,TX?;?::i#11{xl"l*:::: it::vti::::i,.,en,v subject to backup withho,dins becauseiil"li;i"11iil:ffiH[3],:'fl::',:#J[$Ti:"ffi[rxf;'J:t,xffl#h,:,,:t]+liH,1H'r::::;l[:ll',;PJ:i]iffj,*iJ:'LT.iiacquisition orabandbnment or.""c,ieJpiop.*v,i,lJ"rj,i'Ji*ru[iiilffiiilXii,'lTi?iJl,,h:l?#"1"j;:?j"?iJlll?,,Hfs"s: i,t"i".t puii,other than interest and dividends, yor 9r" nLi r.ffi"iiofigrrr'"
"".tification. blrt vorr mrrci nrnrrirra .,^, ,, ^^"-^^. -,; 'T"nl,(lnel,inl generalrv, prvm"nt"certirication, but vou m ust provioe voui lorr'eii ili. ;;.;'iil:, ilt#;;,H$? l"RtTrTl:
General lnstructions o Form 1099-DlV (dividends, including thosefunds)Section references are to the lnternal Revenue Code unless otherwisenoted.
Future developments. For the latest information about developmentsrelated to Form W-9 and its instructi;",:;;;'; [lisiution enactedafter they were published , go to www.irs.g;;li;;;i;.'
Purpose of Form
An individual or entity (Form_W_9 requester) who is required to file anrnformation return with the IRS must obtain'youi coiieli taxpayeridentification number [flN) wnicrr may ue y"'r;;#;i;;rrity number(SSN), individuat taxpayer identification r;r;";it;tii;;doptiontaxpayer identification number tarrrul, or emproy!i'idliniiti"ation number(ElN), to report on an informatron.return the amount paid to you, or otheramount reportable on an information return. E*urpf5" ot informationreturns include, but are not limited to, tne tof lowinJ. -- "
o Form 1 099-lNT (interest earned or paid)
o Form 1099-MISC (various types of income, prizes, awards, or grossproceeds)
o Form 1099-8 (stock or mutual fund sales and certain othertransactions by brokers). Form 1 099-5 (proceeds from real estate transactions). Form 1099-K (merchant card and third party network transactions)o Form 1098 (home mortoage interest), r 09g-E (student roan interest),1098-T (tuition)
o Form 1099-C (canceled debt). Form 1099-4 (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 TlN. \" rv'uu'r r!
lf you do not return Form W-.9 to the requester with a TtN, you might
f;subiect to backup withhotdins. s"" Wil"ii" or"[ri*it,i troing:
5 Address fiu.mOEAreA, anq apt. or
,krul
Cat. No. 10231X
*- W'9
(Rev. October 20i 8)
Department of the Treasuru
lnternal Bevenue Service '
Request for Taxpayerldentification Number and dertification
(Rev.10-2018)
DocuSign Envelope ID: 46A68185-0E46-48C2-A36B-C5324DC95C7D