HomeMy WebLinkAboutCGARD_APP_W9.pdfSMALL BUSINESS ASSISTANCE GRANT APPLICATION
Complete the fillable application in its entirety. Print the completed appiication,
sign and date and email, along with a copy of your W-9, to, ,.''.., ,.. .,
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
/'1C
Name of Business Owner{s):/l"Larca Q** z-a.l,ez
Business Address: t rn wq Q ffcca
Expiration Date of Business License:lLl\tl enzr
/'Ltarcc, 6..,r -,*.t+, ( * ot tlLY )Contact Person Name and Title:
Contact Person E-mail:
contact Person Phone: lfr 4 (l / c; *1 (, tr ()
(Optional) ls this business 51% minority-owned or wsmen-owned (Y/N)
Please initial each to confirm:
\r1 25 or fewer employees
+* A for profit business in the City of Auburn established prior to January \ 2A2O
I
C*o.] tL,t
City of Auburn Business License number: "B ai5 ', ,{ ti,?,5
This is a Rnd 1 grant
for $1,300.00
DocuSign Envelope ID: 63EEC038-0980-4506-BD8F-F5A6925A936B
#_ Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
J-Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
_.,L Business 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:
. 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
disability.
r 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discrimination law or policy, this Agreement may be rescinded, cancelled, or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.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 31,
2021..
e 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.
2
DocuSign Envelope ID: 63EEC038-0980-4506-BD8F-F5A6925A936B
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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 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 xJd-O with my signed application
Applicant Signature:
By signing this document,
Date: iL ',L,' c^ .
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 n
If no, provide reason for denial:
lf no, has notification been sent to applicant? Yes n No D
Grant Payment Date:
City Representative Signature: Date:
3
DocuSign Envelope ID: 63EEC038-0980-4506-BD8F-F5A6925A936B
X
12/23/2020
w-g Request for Taxpayer
ldentification Number and Certification
} Go to www,irs,gov/FonnWg tar instructians and the late$t information,
Give Form to the
requester. Do not
send to the lRS.
4 Exemptions (codes apply only to
certain entities, not individuals; sse
instruction5 on page 3):
Exemption from FATCA reporting
code {if any)
Form
(Rev. October 2018)
Depadment of lhe Treasury
lnternal Bevenue Service
1 Name {as shown on your ir-rcome tax retiirn\. Nar're is reqlrired on this line: do not leave this line blank
fu4arco A
2 Business nameldisregarded entity name, i! diilerent trom above
Childrens Garden
c.j
od&
Co,ooco.oit
oiZo.!c
o- <:soo
ao0)a
Exempl payee code {if anv} _
Requester's name and address loptional)
a{)001-rnt ller-e
T ldentification Number
Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid
backup withholding. For individuals, this is generally your social security number (SSN). However, for a
resident alien. sole proprietor, or disregardeci 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 ta get a
llA/, laier.
Note: lf the account is rn more than one name, see the instructions for line 1. Aiso see What Nafie and
Number To Give the Requester tcr guidelines on whose number to enter.
Employer identification number
Under penalties of perlury, I certify that:
1. The numLrer shown on ihis {orm is my correc.t taxpayer identification number (or I am waiting for a nurnber to be issued tc me)i and
2. I am not subject to backup withholciing because: (a) i am exempt from backup withholding, or (b) I have not been notified by the internal Revenue
Service (lBS) that I am $ubiect to backup wilhholding as a result o{ a failure to repcrt all interest or dividends, or (c) the IBS has notified me that I am
no longer subiect to backup withholding: and
3. I am a U.S. citizen or cther U.S. person {defined below); and
4. The FATCA code(s) entered on this form {if any) indicating that I ai-n exempt {rom FATCA reporting ls correct.
Certilication instructiono. You must cross out item 2 abnve if you have been notified by the IRS that you are currently subject to backup withholdlng because
you have faiied to report all interest and dividends on your tax return. For real estate iransactions, item 2 does not apply. For modqage interest paid,
acquisition or abandonment of secured property. cancellation of debt. contributions to an individual retirement arrangenrent (lHA). and generally. paym€nts
other than interest and dividends- you are nat-r€quiled to sign the certification, bLrt you must provide your correct TlN. See the instructions for Part ll. later.
Sign
Here
General lnstru s
Section references are to the lnternal Revenue Code unless othenr,'ise
noted.
Future developments. For rhe latest information about developments
related to Form W-9 and its instructions, such as legislation erracted
after thev were published, go 1o www.irs.govlFormWg.
Purpose of Form
An indivicjual or entity (Forin W-9 requester) wha is required to file an
information return with the IRS must obtain your correct taxpayer
identiiication number [lN) which may be your social security number
(SSN). individual taxpayer identification number (lTlN), adoption
taxpayer identification number {ATIN), or empioyer identification number
(ElN), to repod on an information return the ernount paid to yau, or other
arnount reponable on an inforrnation retr;rn. Exarnples of information
reiurns include, but are rot limited to. the foliowing.
. Form 1099-lNT (interest earned or paid)
0f
LlaADate )
. Form 1099-DlV (dividends, including those from stocks or mutual
funds)
' Form i099-MISC hrarious types of income, prizes, awards, or gross
proceedsi
. Form 1099-8 (stock or mutual {trnd sales and certain other
transactions by brokers)
. Fornr 1099-S (proceeds fi-om real estate transactions)
. Form 1099-K (merchant card and ttrird party network transactions)
. Forrn 1098 (home moftgage interest), '1 096-E (student loan interest),
1C98-T (tuition)
o Form 1099-C (canceled Cebt)
. Form 1099-4 (acquisition or abandonnrent of secured propefiy)
Use Fomr W-9 only if you are a U.S. person {including a resident
alien), to provide your correct TlN.
lf you do not return Fr:rm W-9 to the requester with a TlN, you night
be subiect to backup witllholding. See What is backup withholding,
later.
3 Check appropriate box for federal tax classi{ication of the person whose name is entered on line 1. Check only one of the ]ioilowinq seven boxes. l
f] individuallsote propr.tetor or I C Corporation E S Corporation I Partnersnip f] Trust/estate
single-member LLC
B Ll*it.o liability company. Enler the tax ciassilication (C=C corporation. S=S corporation. P=Partnershrp) > _
Note: Check lhe appropriate box in the iine above for the tax classificallon of the single-member owner. Do no1 check
LLC if the LLC is classified as a single-rnember 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 that
is disregarded from the owner should check the appropi'iate box for the tax classi{ication of its owner.
I l Other (see instructions) >
5 Address (nlrmber, street. and apt. or suite no.) See instriictions-
1302 16th st Ne
S Citv. state and ZIF ccrie
Auburn Wa 98002
Social security number
Fart I
4 6 4ll o 1 7 1 8 4
Part ll
Signature of
U,S" person
Cat. No. 10231X rorm W-9 (Rev. 10-2018)
DocuSign Envelope ID: 63EEC038-0980-4506-BD8F-F5A6925A936B