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C7 r~ n ~1 ~ ~,, Oepanmeri! m Ea~pTOyme~rc; tJjy j~'jj~jf'/~s~ F~[oiw\~tTaJx~OjeveloJpm/~e`M~: ~.. ~.. 'il Yl is.//V ~i/i Please SII 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 (including Job Opportunity Zone (JOBZ) tax exemptions/credit) and financial assistance agreement signed from AuRrtst 1 1999 through December 31.2004 unless goals have been achieved and reported on a MBAF per Minn. Stat. § 1167.993 to § 1167.995. ^ Businesses receiving JOBZone Benefits must report through 2015 even if goals have been achieved. ^ The follov~ing government agencies must submit a MBAF: 1) any local government agency that signed a business subsidy ageement since January 1, 1999, or represents a population of more than 2,500; 2} all state government agencies authorized to provide business subsidies. ^ 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 awazded after Lune 1 of each year until a report has been submitted. ^ Questions? Call (651) 296-0580. Information on where to mail or fax your completed MBAF(s) is on page 5. An online version of this form is available at www.deedstate.mn.us/Community/subsidies/MBAFForm.htm Cnrfinn 1 • ((_rnntnr Tnfnrmatinnl 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. NamelTitle Phone number Street address City Zip Code 11. Classification of gantor (Mark one. If grantor is entity created 12. Has your organization held a public hearing on and adopted by govt agency, please indicate affiliation. For example, a city criteria for awarding business subsidies in compliance with EDA would check "City government. ') Minn. Stat. § 1167.994? (Mark one.) ^ City government ^ Yes, in 2005 (attach criteria) ^ Yes, in 2005 but have not yet adopted criteria ^ County government ^ Yes, prior to 2005 ^ Regional government If Yes: Hearing Date: Year Criteria Submitted: ^ State government ^ No ^ Other (Please specify) ^ Other (Please attach lanation. 13. Has your organization signed any agreements to award a business subsidy or financial assistance from August 1, 1999 through December 31, 2004 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.) re rted in a reviousl :led MBAF er Minn. Stat. ,¢1167.993 and 1167.994. 14. Name of business or organization receiving subsidy or fmanciai assistance I5. Address where business subsidy or fmancial 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 ofparent corporation below. If more than one, indicate ultimate owner.) ^ No State ZIP Code Name of Minnesota Business Assistance Form (02/Ol/OS) Page 1 of 5 Dept. of Employment and Economic Development