5.1. PCSR 08-24-2004 - Laserfiche WebLink

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I Pi "'p ". limuc 4 Please fill in date agreement signed (same as question 21) Minnesota Business Assistance Form • The Minnesota Business Assistance Form(MBAF) is used to report each business subsidy and financial assistance agreement signed from August 1, 1999 through December 31,2003 unless goals have been achieved and reported in a MBAF per Minn. Stat. §116J.993 to §116J.995. • The following government agencies must submit a MBAF: 1)any local government/agency that signed a business subsidy agreement since January 1, 1999, or represents a population of more than 2,500;2)all state government agencies authorized to provide business subsidies. • If a local or state government agency that is required to report has not done so by April 1,DEED will mail a warning. If it fails to report by June 1, it may not award any business subsidies until a report has been filed. • Questions? Call(651)296-0580. Information on where to mail or fax your completed MBAF(s)is on page 4. Section 1 Grantor Information 1. Name of grantor(funding entity) 2. Name of person completing this form 3. Street address 4. City 5. ZIP code 6. County 7. Phone number 8. Fax number 9. E-mail address 10. Please indicate who in your organization should receive the MBAF if different from the person in Question 2. Name/Title Phone number Street address City ZIP code 11. Classification of grantor(Mark one.If grantor is entity 12. Has your organization held a public hearing on and created by gov't agency,please indicate affiliation. For adopted criteria for awarding business subsidies in example,a city EDA would check "City government.") compliance with Minn. Stat. §116J.994?(Mark one.) • City government • •Yes,in 2004 (attach criteria) • •Yes,in 2004 but have not yet adopted criteria • County government • •Yes,prior to 2004 • •Regional government If Yes. Hearing Date: Year Criteria Submitted: • -State government • •No • 'Other(Please spec.) • 'Other(Please attach explanation.) 13. Has your organization signed any agreements to award a business subsidy or financial assistance from August 1, 1999 through December 31,2003 unless goals have been achieved and reported in a previous filed MBAF? (Mark one.) • •Yes (Complete the remainder of the form unless goals have been achieved and • •No (Stop here,go to section 5 on page 4.) reported in a previously filed MBAF per Minn. Stat.§116.1.993 and§116.1.994.) Section 2 Recipient Information 14. Name of business or organization 15. Address where business subsidy or financial assistance receiving subsidy or financial assistance will be used Street address City State ZIP code 16. Does the recipient have a parent corporation?(Mark one.) • •Yes(Indicate name and address of parent corporation below. If more than one, indicate ultimate owner.) • No Name of parent corporation Street address City State ZIP code Minnesota Business Assistance Form(1/14/04) Page 1 of 4 Dept.of Employment &Economic Development