ED_900B_2_1-V2.1.pdf

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ED-900B – Beneficiary Information Form D:20060519172049- 04'00' D:20060519173626- 04'00' ..\..\Unknown.png EDA Logo OMB Number: 0610-0094Expiration Date: 10/31/2024 ED-900B – Beneficiary Information Form Please note: in order to be complete, this form must be signed and dated in two places, following section D and section E.

By signing this form, the beneficiary is providing an estimate of jobs and private investment that are projected as a result if the project is funded and is not a legal assurance. While the ED-900B does not create a repayment obligation if the estimates are not achieved, EDA expects the form to represent a good-faith estimate of projected impact as a result of the proposed investment. EDA carefully reviews project impacts from the ED-900B against publicly available data to gauge the reasonableness of estimates provided based on project type, geography and past work and estimates and information reported erroneously can impact the competitiveness of applications.

A. General Information A.1. Proposed EDA Project Title:

Lead Applicant:

EDA provides competitive grant assistance to eligible public entities to support the construction of public infrastructure that helps create the competitive environment where companies can create and retain jobs and invest private capital.

This form must be completed by an authorized or corporate representative of the identified beneficiary organization whose position reflects the authority required to make these assurances (such as the authority to hire employees). Legal authorization for a corporate official may be specified in the Corporation’s or LLC’s formation documentation, bylaws, or similar document and under the laws governing the Virgin Islands, American Samoa, Guam and the Commonwealth of the Northern Marianas Islands. In the case of an individual executing this form as a sole proprietor or private owner, the sole proprietor’s or owner’s role and position must be indicated. For other circumstances, please contact your Regional Office.

A.2. Beneficiary Organization Name:

A.3. Beneficiary Organization Address:

Street 1:

Street 2:

City:

County:

State:

Province:

Country:

Zip/Postal Code:

A.4. Is the company Foreign owned or a US subsidiary of a Foreign owned company?

A.5. List the NAICS code for the beneficiary industry. NAICS codes can be identified at https://www.census.gov/naics/.

B. Products or Services Briefly describe the products or services your business produces or sells, and if any of these products or services are exported out of the country.

C. Estimated Impact of the EDA Investment

• Jobs created should be a direct result of this project. For example, a water or sewer project that will service a firm and allow the firm to grow its capacity and hire 60 full-time workers. In this example, 60 would be entered in the table under jobs created.

• Jobs saved means that without this project the jobs listed would be lost. For example, a company is experiencing adverse production impacts due to ongoing disruptions to its wastewater system. If the disruptions continue, it could jeopardize the company’s ability to continue operating at the location and risks 40 jobs being lost. If the proposed project would address the disruption and allow the plant to continue operating at the proposed site, then those 40 jobs would be identified as jobs saved. Please note, the current number of employees of a beneficiary should not be included as jobs saved unless there is a confirmed threat that the jobs would be lost (i.e., the company would move or close) if the project were not undertaken.

• Only long-term, full-time direct jobs should be listed in the table. Part-time jobs should be converted to full-time equivalents (sum the total part-time hours worked per week and divide by the hourly work week for full-time employees, normally 35-40 hours).

• Private Investment means the total private sector capital investment made because of the EDA investment, including investments in new plant and equipment. Do not report private sector contributions to project construction or loan fund capitalization reported above in this section.

Jobs Created Jobs Saved Private Investment D. Provision of Data on the EDA Investment The Economic Development Administration (EDA) tracks job and private investment resulting from its awards. If this application results in an award, each beneficiary must provide to the successful recipient job and private investment results up to 9 years after the EDA grant award in order to assist the grantee with fulfilling these reporting requirements.

Check box to indicate that your company intends to provide the recipient with information on jobs and private investment generated as a result of the EDA project.

Signature of authorized representative for the beneficiary organization Date Name and title of beneficiary organization authorized representative Name Title E. Assurances by Beneficiary that is an "Other Party" An authorized or corporate representative of any beneficiary that is considered an “Other Party” as defined below, must also sign to show that the beneficiary intends to comply with the U.S. Department of Commerce (DOC) and EDA regulations described below.

As defined at 13 C.F.R. § 302.20(b)(1), an “Other Party” is an entity that intends to create or save 15 or more permanent jobs as a result of this EDA-supported project and is specifically named in the application as benefiting from the project or will be located in a building; port; facility; or industrial, commercial, or business park constructed or improved in whole or in part with EDA investment assistance prior to EDA's final disbursement of funds.

By submitting these assurances, the Other Party certifies that it will comply with the following requirements:

• Section 601 of Title VI of the Civil Rights Act of 1964, as amended (42 U.S.C. 2000d et seq.), and the DOC's implementing regulations at 15 C.F.R. part 8, which proscribe discrimination on the basis of race, color, or national origin.

• 42 U.S.C. 3123, 42 U.S.C. 6709, and the DOC’s regulations at 15 C.F.R. part 8a, which proscribe discrimination on the basis of sex.

• Section 504 of the Rehabilitation Act of 1973 (29 U.S.C. 794), and the DOC’s implementing regulations at 15 C.F.R. part 8b, which proscribe discrimination on the basis of disabilities.

• The Age Discrimination Act of 1975, as amended (42 U.S.C. 6101 et seq.), and the DOC’s implementing regulations at 15 C.F.R. part 20, which proscribe discrimination on the basis of age.

Signature of authorized representative for the beneficiary ("Other Party") entity Date Name and title of beneficiary organization authorized representative Name Title