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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 (including Job Opportunity Zone (JOBZ) tax exemptions/credit) and financial assistance agreement signed from August 1, 1999 through December 31, 2004 unless goals have been achieved and reported on a MBAF per Minn. Stat. § 116J.993 to § 116J.995. Businesses receiving JOBZone Benefits must report through 2015 even if goals have been achieved. 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. 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. 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.deed.state.mn.us/Community/subsidies/MBAFForm.htm 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 created by gov’t agency, please indicate affiliation. For example, a city EDA would check “City government.”) City government County government Regional government State government Other (Please specify)_______________________________ 12. Has your organization held a public hearing on and adopted criteria for awarding business subsidies in compliance with Minn. Stat. § 116J.994? (Mark one.) Yes, in 2005 (attach criteria) Yes, in 2005 but have not yet adopted criteria Yes, prior to 2005 If Yes: Hearing Date: _________ Year Criteria Submitted: _________ No 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, 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.) reported in a previously filed MBAF per Minn. Stat. §116J.993 and §116J.994.) Section 2: Recipient Information 14. Name of business or organization receiving subsidy or financial assistance 15. Address where business 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 (02/01/05) Page 1 of 5 Dept. of Employment and Economic Development