HomeMy WebLinkAboutContractCAG-21-301
12-20-2021
Approved by Patrice Kent via 12/15/2021 email
Small Business Resiliency Grant Fund Program
One-Time Reimbursement Form
GRANT RECIPIENT NAME _______________________________________________
ADDRESS _______________________________________________
GRANT AGREEMENT NO. _______________________________________________
EXPENSES TO BE REIMBURSED (UP TO $7,500):
EXPENSES AMOUNT DATE RANGE
PAYROLL
RENT
UTILITIES
MACHINERY AND EQUIPMENT
TECHNOLOGY EQUIIPMENT
VIRTUAL
REVAMP/CONVERSION
PPE/SANITATION COSTS
MODIFICATION TO BUS.
OPERATIONS
MARKETING
TOTAL EXPENDITURES
☐Attached supporting documentation for expenses to demonstrate, by date, expenses were incurred
between the eligible dates of March 3, 2021 and December 31, 2021. Sufficient documentation
includes:
1.Receipts
2.Payroll reports
3.Copies of cancelled checks
☐Attached IRS Form W9.
☐Submitted a completed invoice within 30 days of execution of the agreement, but in no case after
March 4, 2022.
*REMINDER: Grant funds may .be taxable. Please consult with your financial advisor/tax professional for
guidance. If it is required by the IRS, a 1099 form will be issued to the Beneficiary.
_________________________________________________________________________________
Business Owner/Authorized Agent Signature Date
FOR CITY USE ONLY:
☐Supporting documentation for expenses are determined to be eligible for reimbursement under the Renton
Small Business Resiliency Grant Fund program.
☐Expenditures were incurred between March 3, 2021 and December 31, 2021.
☐An IRS W-9 form has been reviewed.
☐Reimbursement submitted to the City no later than March 4, 2022.
___________________________________________________________________________________
COR Employee Signature Date