HomeMy WebLinkAboutSCAMP 2.pdfSMALL BUSINESS ASSISTANCE GRANT APPTICATION
'!ri#*:r[:;fiitaurants, dinins & drinkins estabtishments without drive-thru
complete the fillable application,ri its entirety. rri.r1! the completed application,sign a*d dete and .*iir =io*e-;ith a capv;;;;;w_9, tc: oinzoauburnwa.gov
Applications can also be mailed to the following:City of Auburn
Attn: Office of Economic Devetopment
25 W Main
Auburn, WA 9g001
TC BE COMPLETEB BY APFI.ICAtrT
Name of Busineru,
Name of Business ownerfrt, AfI[.r eSl,^r tI**s el^{
Business Address: ./,asrn r W,ft 7ffi6<
Gty of Auburn Business License number: @
Expiration Date of Business License: , l - ;,.., -),.:_;
Contact person Name and Title: _ n \*l * U,V<y,
Contact Person E-mail:
n c g)r,/a
Contact person phone:
(optional) rs this business 5r% minority-owned or women-owned (y/N) ,, [,
Please initial each to confirm:
-&' Are a restauran! dining or drinking estabrishment without a driye-thru
& A for profit business in the city of Auburn estabrished prior to January r, zazat-_.-_,_
DocuSign Envelope ID: A1B99F66-C8BB-4BB3-A17E-C594261D1DAF
Ifu Business has a physical presence {address} tocated 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
b Business in good standing (including: current City of Auburn business license;
current on alt 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 Prograrn. 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 andfor employees are not
discriminated against due to race, creed, color, religion, sex, national origin, or
disability.. 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discrimination law or policy, this Agreement may be rescinded, cancelled, or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 shall the 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 L099 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.
DocuSign Envelope ID: A1B99F66-C8BB-4BB3-A17E-C594261D1DAF
Applicant shall defend and indemnifu 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 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.
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
,1" , x \ l)_.s*
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
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?A NF AAIIhI F?FR NI' AI-l' F-A FF
Gran* Analiaa*ian lEranlarl) Vac l-i f,t^ n
lf no, provide reason for denial;
lf no, has notification been sent to applicant? Yes E Na tr
Grant Payment Date:
City Representative Signature;Date:
DocuSign Envelope ID: A1B99F66-C8BB-4BB3-A17E-C594261D1DAF
X
n/a
11/30/2020