Fillable Utility Fee App Fillable (City of Farmington)

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Utility Fee App Fillable (City of Farmington)

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Utility Fee Program – Grant Application
A COPY OF YOUR CURRENT UTILITY BILL MUST BE SUBMITTED WITH THIS APPLICATION
The Utility Fee Program aims to provide a one-time direct assistance grant for city utility fees for
businesses with 100 employees or less company-wide within the City of Farmington. Grant applications
will be reviewed by the City of Farmington on a rolling basis and accepted based upon fund availability.
Grant applications cannot be accepted after the allotted fund balance has been used. The Utility Fee
Program is funded from a pool of $10,000 through the Economic Development Authority (EDA).
APPLICANT INFORMATION
NAME OF APPLICANT(S):
_____________________________________________________________________________________
BUSINESS INFORMATION
LEGAL NAME OF BUSINESS: ______________________________________________________________
ADDRESS: ____________________________________________________________________________
CITY, STATE, ZIP: _______________________________________________________________________
BUSINESS PHONE: ______________________________________________________________________
EMAIL ADDRESS: _______________________________________________________________________
FEDERAL TAX ID #: _____________________________________________________________________
NUMBER OF EMPLOYEES COMPANY-WIDE: _________________________________________________
FUNDING INFORMATION
Awarded grant funding shall not exceed $500 or the current cost of the City of Farmington issued utility
bill. If accepted, the grant funds will be directly transferred to the specified business utility account
within the City of Farmington. Any additional outstanding utility charges outside of the one-time direct
assistance grant will still be the responsibility of the business to pay (e.g. a utility bill of $650 with a one-
time grant of $500 means the business will still owe the remaining $150 of their utility bill).
TOTAL GRANT AMOUNT REQUESTED – $_______________________
I/We declare that the information provided on this application and the accompanying attachment is true
and complete to the best of my/our knowledge. I/We understand that any intentional misstatements
will be grounds for disqualification and that the City of Farmington/EDA has the right to verify this
information.
APPLICANT(S)
_______________________________________ DATE: __________________________
_______________________________________ DATE: __________________________
APPLICATION SUBMITTAL
To apply, please attach a completed Utility Fee Program – Grant Application along with a copy of your
current City of Farmington utility bill to CMuller@FarmingtonMN.gov.
MINNESOTA DATA PRACTICES ACT—TENNESSEN WARNING
In accordance with the State of Minnesota Government Data Practices Act, the City of Farmington is
required to inform you of your rights as they pertain to the confidential information collected from you.
Confidential data is information which is not available to you or the public. The personal information we
collect about you is private.
The information collected from you and from other agencies or individuals is used to determine the
disposition of your application with the city.
The dissemination and use of the data collected is limited to that necessary for the administration and
management of the Utility Fee Program. Persons or agencies with whom this information may be
shared, include:
1. City of Farmington personnel administering the grant program
2. City Council members, Economic Development Authority members
3. Contracted private auditors
4. Law enforcement personnel
5. Those individuals or agencies to whom you give your express written permission
NOTICE PURSUANT TO MS.60A.955
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Utility Fee App Fillable (City of Farmington)

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Completed 15 July 2020

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