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SMALL BUSINESS ASSISTANCE GRANT APPLICATION
(Round Two - Restaurants, dining & drinking establishments without drive-thru capabilities, and gyms, training centers, performing arts centers and theaters 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(s): ____________________________
Business Address: ____________________________________
City of Auburn Business License number: __________________
Expiration Date of Business License: ______________________
Contact Person Name and Title: _________________________
Contact Person E-mail: ________________________________
Contact Person Phone: ________________________________
(Optional) Is this business 51% minority-owned or women-owned (Y/N) _______
Please initial each to confirm:
____ Are a restaurant, dining & drinking establishment without drive-thru
capabilities, or a gym, training center, performing arts center or theater.
____ A for profit business in the City of A uburn established prior to January 1, 2020.
Auburn FieldhouseUSA
Gary Oliver, John Vines, Terry Casey
1101 Outlet Collection Way #1275 Auburn, WA 98001
604397576
January 31, 2021
Chris Nance - Facility Manager
cnance@fieldhouseusa.com
214-934-0997
N
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____ Business has a physical presence (address) located within a commercial zone
within the City of Auburn. (Home based businesses do not qualify).
____ Business was adversely impacted by mandatory and/or voluntary business
closures directly related to the public health response related to COVID-19
____ 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.
•In 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.
•In 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 1099 will be
issued to all grant recipients, as required by the IRS, 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.
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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 W-9 with my signed application
Applicant Signature: _________________________________ Date: ______________
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 ☐ No ☐
If no, provide reason for denial: _______________________________________
If no, has notification been sent to applicant? Yes ☐ No ☐
Grant Payment Date: _____________________________________________________
City Representative Signature: _________________________Date: ___________
12/22/2020
DocuSign Envelope ID: DCC96024-6444-43E8-A7D9-2BE10B5CA4A7
12/23/2020
X
Form w-g
(Rev. October 2018)
Department or the Treasury
Internal Revenue Service
Request for Taxpayer
Identification Number and CertificaUon
> GO to www.irs.govlFormW9 for instructions and the latest information.
Give Form to the
requester. Do not
send to the IRS.
1 Name (as, shown on your inco; tax rel
A s i .- I
/-%u 0 U y' %/'s %' % € -(,ur,tff ,eis,:eSqlu,ired o%n tLhis_LlineL,do not leave this line blank.
2 Business name/disregarded e'ntity name, if different from above'
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.
[1 Individual/sole proprietor Or € C Corporation € s Corporation € Partnership 0 Trust/estate
single-member LLC
Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) k _P__i
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 disreaarded from the owner for u.s. federal tax ournoses. Otherwise. a sinale-member LLC that
4 Exemptions (codes apply only to
certain entities, not individuals; see
instructions on page 3):
Exempt payee code (if any)
Exemption From FATCA reporting
code (if any)
is disregarded from the owner should check the appropriate box for the tax classification of its owner.
0 0ther (see instructions) >(Applies to accounts maintained outside the U.S.)
s (AodXdr,,ess S(number<epet,,, a%,nd,;. or,f%rK.(S,eet:n%,structi7%n,X l s 'vr 'rk , (O ().
Requester's name and address (optional)
6 City, state, and ZIP cue l ' )
r S -t'u ! /, n '7
1"'-vs5'U=,1)" '')05')
7List account numtbr(s) Here (optional)
g Taxpayer Identification Number (TIN)anti
Enter lour 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 disregarded entity, see the instructions for Part 1, later. For other
entities, it is your employer identification number (EIN). If you do not have a number, see How to get a
TIN, later.
Note: If the account is in more than o5ie name, see the instructions for line 1. Also see What Name and
Number To Give the Requesterfor guidelines on whose number to enter.
9 3 3 -"7
')1 'Z-Z ?/(:j,
ffl Certification
Under penalties of perjury, I certify that:
Social security number
or
' Errployer i(enti'-icat-on rumter
1. The number shown on this form is my correct taxpayer identification number (orl am waiting for a number to be issued to me); and
2.-1 am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue
Service (IRS) that I amsubject to backup-withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified 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 reporting is correct.
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because
you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,
acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments
other than interest and dividends; you are not required -to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.
General Instructions
Section references are to the Internal 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 to 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 (TIN) which may be your social security number
(SSN), individual taxpayer identification number (ITIN), adoption
taxpayer identification number (ATIN), or employer identification number
(EIN), 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.
* Form 1 099-INT (interest earned or paid)
* Form 1 099-DIV (dividends, including those from stocks or mutual
funds)
* Form 1 099-MISC (various types of income, prizes, awards, or gross
proceeds)
* Form 5 099-B (stock or mutual fund sales and certain other
transactions by brokers)
* Form 5 099-S (proceeds from real estate transactions)
* Form 4 099-K (merchant card and third party network transactions)
* Form 1098 (home mortgage interest), 1 098-E (student loan interest),
1 098-T (tuition)
* Form 5 099-C (canceled debt)
* Form 1 099-A (acquisition or abandonment of secured property)
Use Form W-9 only if you are a u.s. perSOn (including a resident
alien), to provide your correct TIN.
If you do not return Form W-9 to the requester with a TIN, you might
be subject to backup withholding. See What is backup withholding,
later.
Cat. No. 10231X Form w-g (Rev. 10-2018)
12/22/2020
DocuSign Envelope ID: DCC96024-6444-43E8-A7D9-2BE10B5CA4A7