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Home My WebLink AboutGARGO2.pdf1 SMALL BUSINESS ASSISTANCE GRANT APPLICATION ;ZŽƵŶĚdǁŽͲZĞƐƚĂƵƌĂŶƚƐ͕ĚŝŶŝŶŐΘĚƌŝŶŬŝŶŐĞƐƚĂďůŝƐŚŵĞŶƚƐǁŝƚŚŽƵƚĚƌŝǀĞͲƚŚƌƵĐĂƉĂďŝůŝƚŝĞƐ͕ĂŶĚŐǇŵƐ͕ƚƌĂŝŶŝŶŐĐĞŶƚĞƌƐ͕ƉĞƌĨŽƌŵŝŶŐĂƌƚƐĐĞŶƚĞƌƐĂŶĚƚŚĞĂƚĞƌƐŽŶůǇ͘Ϳ Complete the fillable application ŝŶŝƚƐĞŶƚŝƌĞƚǇ. Print the completed application, sign and date and email͕ĂůŽŶŐǁŝƚŚĂĐŽƉǇŽĨǇŽƵƌtͲϵ͕ to: OEDϮ@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: ____ ƌĞĂƌĞƐƚĂƵƌĂŶƚ͕ĚŝŶŝŶŐΘĚƌŝŶŬŝŶŐĞƐƚĂďůŝƐŚŵĞŶƚǁŝƚŚŽƵƚĚƌŝǀĞͲƚŚƌƵ ĐĂƉĂďŝůŝƚŝĞƐ͕ŽƌĂŐǇŵ͕ƚƌĂŝŶŝŶŐĐĞŶƚĞƌ͕ƉĞƌĨŽƌŵŝŶŐĂƌƚƐĐĞŶƚĞƌŽƌƚŚĞĂƚĞƌ͘ ͺͺͺͺĨŽƌƉƌŽĨŝƚbusiness in the ŝƚǇŽĨA uburn established prior to January 1,ϮϬϮϬ͘ Barrio Wods LLC, dba Gargoyle CrossFit Alvin Dela Cruz 1508 O Street SW #102, Auburn, WA. 98001 BUS-30402 12/31/2020 Jennifer Dela Cruz gargoylecf@gmail.com (253) 218-8925 Y ADC ADC DocuSign Envelope ID: 2D1B034A-5BA7-4D59-952B-AA865C5AB816 2 ____ 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: x 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.x The Grantee affirms that residents, customers and/or employees are not discriminated against due to race, creed, color, religion, sex, national origin, or disability.x 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.x In no event shall the City’s financial responsibility exceed the approved amount, set forth below.x The Grantee is responsible for any and all costs or liability arising from the Grantee’s failure to so comply with applicable law.x 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.x 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. ADC ADC ADC DocuSign Envelope ID: 2D1B034A-5BA7-4D59-952B-AA865C5AB816 3 x Applicant shall defend and indemnify the City and its employees from andagainst any claim, injury, liability, loss, cost and/or expense or damage includingall costs and reasonable attorney’s fees, arising from or alleged to arise from theactivity or event.x 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.x 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).x I am the duly authorized representative of the entity named above and can bind the entity to the terms of this Agreement.x 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.x I have Provided a current IRS W-9 with my signed application Applicant Signature: _________________________________ Date: ______________ ǇƐŝŐŶŝŶŐƚŚŝƐĚŽĐƵŵĞŶƚ͕/ĂƚƚĞƐƚƚŚĂƚŶŽĞǀĞŶƚŚĂƐŽĐĐƵƌƌĞĚĂŶĚŶŽĐŽŶĚŝƚŝŽŶĞǆŝƐƚƐƚŚĂƚŝƐůŝŬĞůǇƚŽƌĞƐƵůƚŝŶ ƚŚĞĚĞďĂƌŵĞŶƚŽƌƐƵƐƉĞŶƐŝŽŶŽĨƚŚĞďƵƐŝŶĞƐƐĨƌŽŵĐŽŶƚƌĂĐƚŝŶŐǁŝƚŚƚŚĞh͘^͘'ŽǀĞƌŶŵĞŶƚŽƌĂŶǇĂŐĞŶĐǇŽƌ ŝŶƐƚƌƵŵĞŶƚĂůŝƚǇƚŚĞƌĞŽĨ͕ĂŶĚƚŚĞďƵƐŝŶĞƐƐŝƐŶŽƚŶŽǁĂŶĚŚĂƐŶŽƚďĞĞŶƐƵďũĞĐƚƚŽĂŶǇƐƵĐŚĚĞďĂƌŵĞŶƚŽƌ ƐƵƐƉĞŶƐŝŽŶ͘ TO BE COMPLETED BY CITY STAFF Grant Application Granted? Yes տ No տ If no, provide reason for denial: _______________________________________ If no, has notification been sent to applicant? Yes տ No տ Grant Payment Date: _____________________________________________________ City Representative Signature: _________________________Date: ___________ _______________________ ĞƐƚƚŚĂƚ ŶŽĞǀĞŶƚŚĂƐŽĐĐƵƌƌĞĚĂĂ 12/28/2020 DocuSign Envelope ID: 2D1B034A-5BA7-4D59-952B-AA865C5AB816 X 1/7/2021 Form W-9 (Rev. October 2018) Department of the Treasury Internal Revenue Service Request for Taxpayer Identification Number and Certification a Go to www.irs.gov/FormW9 for instructions and the latest information. Give Form to the requester. Do not send to the IRS. Pr i n t o r t y p e . Se e S p e c i f i c I n s t r u c t i o n s on p a g e 3 . 1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank. 2 Business name/disregarded entity 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. Individual/sole proprietor or single-member LLC C Corporation S Corporation Partnership Trust/estate Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) a 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 disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that is disregarded from the owner should check the appropriate box for the tax classification of its owner. Other (see instructions) a 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) (Applies to accounts maintained outside the U.S.) 5 Address (number, street, and apt. or suite no.) See instructions. 6 City, state, and ZIP code Requester’s name and address (optional) 7 List account number(s) here (optional) Part I Taxpayer Identification Number (TIN) 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 disregarded entity, see the instructions for Part I, 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 one name, see the instructions for line 1. Also see What Name and Number To Give the Requester for guidelines on whose number to enter. Social security number – – or Employer identification number – Part II Certification Under penalties of perjury, I certify that: 1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and 2. I 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 am subject 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. Sign Here Signature of U.S. person a Date a 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.gov/FormW9. 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 1099-INT (interest earned or paid) • Form 1099-DIV (dividends, including those from stocks or mutual funds) • Form 1099-MISC (various types of income, prizes, awards, or gross proceeds) • Form 1099-B (stock or mutual fund sales and certain other transactions by brokers) • Form 1099-S (proceeds from real estate transactions) • Form 1099-K (merchant card and third party network transactions) • Form 1098 (home mortgage interest), 1098-E (student loan interest), 1098-T (tuition) • Form 1099-C (canceled debt) • Form 1099-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-9 (Rev. 10-2018) . See the instructions for Part I ding those from stocks or m nds, you are not required to sign the cert ctions U.S. person Signature of Date Sign Sign Here Alvin Dela Cruz Barrio Wods LLC dba Gargoyle CrossFit 1508 O St. SW #102 Auburn, WA. 98001 4 7 2 3 8 2 0 2 7 DocuSign Envelope ID: 2D1B034A-5BA7-4D59-952B-AA865C5AB816