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ID S i � r y Department of Employment 1F and Economicllevolopment /6!L esotor 4-17-06 Please fill in date agreement signed(same as question 21) 2010 Minnesota Business Assistance Form for Non-JOBZ Projects • ■ Use the Minnesota Business Assistance Form to report each business subsidy and financial assistance agreement signed from August 1. 1999 through December 31,2009 unless goals have been achieved and reported on a MBAF per Minn.Stat.§116J.993 to§116J.995. You may complete and submit this form online,instead of submitting a paper version. ■ The following government agencies must submit a MBAF: 1)any local govemment/agency that signed a business subsidy agreement since January 1,2005,or represents a population of more than 2,500;2)all state government agencies authorized to provide business subsidies;3)business assistance that exceeds$150,000. ■ Executive Order 08-01 at http://www.governor.state.mn.us/priorities/governorsorders/executiveorders/PROD008598.html requires that recipients for all business subsidy agreements signed on or after January 29,2008,to comply with the Immigration Act of 1986,as amended. The recipient of business assistance must certify that it is currently participating in the E-Verify program located at http://www.uscis.gov and that all newly hired employees hired on or after January 29,2008 are eligible for employment in the United States throughout the term of the business assistance. in DEED will contact any local or state government agency that is required to report but has not done so by April 1. Business assistance may not be awarded after June 1 of each year until a report has been submitted. in Questions? Call(651)259-7179. Information on where to mail or fax your completed MBAF(s)is on page 5. Section 1: (Grantor Information) 1.Name of grantor (funding entity): City of Elk River 2.Name of person completing this form: Catherine Mehelich 3.Street address: 13065 Orono Parkway 4.City: Elk River 5.Zip Code: 55330 6.County: Sherburne 7.Phone number: 763.635.1041 8.Fax number: 763.635.1090 9.E-mail address: cmehelich@ci.elk-river.mmus 4111 10.Please indicate who in your organization should receive the MBAF if different from the person in Question 2. Name: Title: Street Address: City: I Zip Code: Phone Number: . Email Address: 11.Classification of grantor(Mark one.If grantor is entity created 12.Has your organization held a public hearing on and adopted by gov't agency,please indicate affiliation. For example,a city criteria for awarding business subsidies in compliance with EDA would check"City government.') Minn.Stat.§ 116J.994? (Mark one.) ®City government ❑ Yes,in 2010(attach criteria) ❑ Yes,in 2010 but have not yet adopted criteria ❑County government Z Yes,prior to 2010 ❑Regional government If Yes: Hearing Date: 5/15/06 Year Criteria Submitted: 2006 ❑State government ❑ No ❑Other(Please specify): ❑ 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 31,2009 unless goals have been achieved and reported in a previously 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. §1161.993 and§1161.994.) Section 2: Recipient Information 14.Name of business or organization 15.Address where business subsidy or financial assistance receiving subsidy or financial assistance: The Bank of Elk River will be used Street address:630 Main Street City,State,Zip Code:Elk River.MN 55330 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(02/10/10) Page 1 of 5 Dept.of Employment and Economic Development