HomeMy WebLinkAboutPGRILL 2.pdfSMALL BUS!NESS ASSISTANCE GRANT APPLICATION
(Round Two - Restauronts, dining & drinking establishments without drive-thru
copabilities only)
Complete the fillable application rn 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: f on & '- t^4\n<'+- G'nf //
Name of Business Owner 1s1: .h ' k"- 7e t's k.---,
Business Address: I S z 5,4 5*--u-'* l"'E s n;1<- I lo
City of Auburn Business License number: B h S^ ?27{3
Expiration Date of Business License: ,'t/. *
Contact Person Name and Title: ./14;k*- /q asku ,, e1,uLa' 7
Contact Person E-mail, r'- -t*^ r r^^,, . ..^
contact Person Phone: ('oo\ zx s - Y i 7 ?----\-----------
(Optional) ls this business 51% minority-owned or women-owned (Y/N)
Please initial each to confirm:
@Arc a restaurant, dining, or drinking establishment without a drive-thru
"flfor
profit business in the City of Auburn established prior to Januar y 1., 2O2o
DocuSign Envelope ID: 170BDE24-7A2E-4922-9942-884E3639C5DB
'@eusiness has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
Lt/-eusiness was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
ryTusiness 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:
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 Discrimination Act.
o The Grantee affirms that residents, customers and/or employees 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 refusalto complywith 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discrimination law or policy, this Agreement may be rescinded, cancelled, or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 liability arising from 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 advisor for guidance. A 1099 will be
issued to all grant recipients, as required by the lRS, no later than January 3L,
202t.
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: 170BDE24-7A2E-4922-9942-884E3639C5DB
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.
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).
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
Applicant Signature : 'aa4 -,= Date: l l 7 "'-t'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 n No tr
lf no, provide reason for denial:
!f no, has notification been sent to applicant? Yes tr No tr
Grant Payment Date:
City Representative Signature:Date:
o
DocuSign Envelope ID: 170BDE24-7A2E-4922-9942-884E3639C5DB
X
11/30/2020
uuuuorgil trilvcrupE ru
,",- Ulf'9
(fffl. Octobs 2018)
tlepart nenl ol lhc TreaslYy
lnlernal Flevenue Servr,e
Request for Taxpayer
ldentlflcatlon Number and Gertlflcatlon
> Go lo www.lrs.govlFormW lor lnstructlons and tho lalest lnformatlon.
Give Forrn to the
requester. Do not
send to the lRS.
Name (as m y$;r incorne lax retumi. Nams is m rhis line: do nol leave this lrne HankooJ rtl oq LLL
aioO!(!
o.oocco>=ao
og
=6&trsooaooott)
Check appropriate box lor federal tax classilicatjon ol the person whose nilm€ is entered on line 1. Check only one o{ the
lollowing seven boxes.
f] lndiviouaysots proprietor or I c corporut on
single-member LLC
I t-rmiteO liability oompany. Enler th6lax classrtication (C=C corporation, S=S corporadon, P=Partnership)>
ilote! Check lh€ appiopriat€ box in the line above for lhe lax ilassificatiofl ol the single-member owner. Oo nol check
LLC if the LLC is classified as a single-member LLC thal is drsegarded ,rom the owner untess the o.*ner of the LLC is
another LLC thal is not disregarded trom the owner lor U.S. federal tax purposes. Othembe, a srngle-member LLC
is disregsrdo'd fiom the owner should check the appropriate box for the lax classificstim of its owner.
5 Address (numb6r, str€€!. and apt- or suire no.) S€€ instructions.
{ Szs { /uE #/to
6 City, slate. and ZP code
,fi,*L+-^ , W4 l€ooz-
)ss name/disregarded eotity narndtrditferent,rorn above
fa--Co r1(rqa4a- G -t / l
4 Exemptrans (codes appty only to
corlarn entifi€s, not indiviluals; seeinstnctiofls on page 3):
Exempt peyee cod€ [f Bny]
Eremption trom FATCA reporting
code (rf any)
(rrpaer lp @, s atrlsrcd drtdc ltr U S
Requester's narn€ and address
7 List account nu
Number
Enter your TIN in the appropriate box. The TIN prov.ded must match the'name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, lor a
resident alien, sole proprietor, or dsregarded entity, see the instructions lor Parl l, laler. For other
enlities, it is your employer identificataon number (ElN). lt you do not have a numb€r. see f/ow to get a
1'I& laler.
Note: ll the account is in more than one name, see lhe instructions for line 1. Also see What Nafie ud
Number To Give t le Beguesler{or guidel nes on whose number lo enter.
Under penalties ol periury, I ce,tl{y that:
1. The number shown on this Jorm is my correct taxpayer identification number (or I arn waiting tor a number to be issued to me); and
2. t am nol subiect to backup wilhholding because: (a) I am exempt lrom backup withholding, or (b) I have not been notrfied by lhe lntemal Revenue
Service (lRS) that I am subiect to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notitied me lhat I am
no longer subiect to backup withholding: and
3. I am a U.S. citizen or olher U.S. person (detined below): and
4. The FATCA code(s) entered on this form (if any) indicaling that I am exempt lrom FATCA reporling is conect.
CerUficatjon instructlons. You must ctoss out item 2 above if you luve been notili€d by the IRS that you are cunenlly subiecl to backup withholdirg because
you have lailed to reporl all interest and dividends on your lax return. For reat estale transactions, item 2 does not appty. For mortgage interest paid,
acquisition or abandonmenl of secured property, cancellalion of debl, contribulions to an lrdividual relirernent anangement 0RA), and gensra,ly, payments
other than interest and dMdends, you are not required to sign the certilication, but you must provide your conect TlN. See the instructions for Part ll. later.
Signature of
U.S. person )Orr", I I
General lnstructions
S€ction references are lo lhe lnlemal Revenue Code unless oth€rwise
noted.
Fulure developments. For the latost informalioo aboul developments
related to Fom W-9 and ils inslructions, such as legislation enacted
atter they were publbhed. go to wwr,y.,rs.govlFormW9,
Purpose of Form
An individual or ent;ty (Form W-9 requester) who is required to file an
inforn:alion retum rvith the IRS must obtain your conect taxpayer
identificalion number fl'lN) which may be your social security number
{SSN), lndividual taxpayer rdenlificalion number flTlN), adoption
taxpayer identification number (ATIN). or ernployer identitacation number
(ElM. to report on arr lnformalion retum the amount paid to you, or olher
amount reportable on an intormation retum. Examples of intormation
retums include. but are not limiled to, the lollowing.
. Form 1099 lNT {inlerest eamed or paid)
. Form 1@9-Dw (dividends, including those lrom stocks or mutual
tunds)
. Form 1098-MISC (various types o, income, prizes, awards, or grGs
proceeds)
r Form 1099-8 (stock or mutual fund sales and ce(ain other
hansacl ioos by brokers)
o Form 1o99-S (proceeds trom real eslate transactions)
. Form 1099-K (merchanl card and thard party networt< transactions)
. Form 1098 (home mortgage interest), 1098-E {student toan interesl),
1098-T (tuition)
o Form 1099-C (canceled debt)
. Form 1099-A (acquisitlon or abandonment of secured Foperty)
Use Form W-9 only if you are a U.S. person (including a resident
alien), to provido your conecl TlN.
lf you do not retum Form W-g to tl€ requester with a nN, yw might
be sub/bct to b&kup withholding. See What is backup whhholding,
late,.
Cat. No. 1@31X Form W-9 lRev 1O-2O1Br
2bSign
Here
DocuSign Envelope ID: 170BDE24-7A2E-4922-9942-884E3639C5DB