ED-900B Beneficiary Information Assurances with Instructions

ED-900B – Beneficiary Information Form

1. General Information

1. Proposed EDA Project Title: {(Project Name)Text Field} proposed by {(Lead Applicant Name)Text Field}

2. Beneficiary Organization Name: {Text Field}

3. Beneficiary Organization Address: {Address1}{Address2}{City}, {ST} {Zip}

4. Please characterize the main industry/field of this beneficiary organization: {Text Field}

2. Estimated Impact of the EDA Investment

1. As indicated in the table below, as a direct result of the proposed scope of work, {Beneficiary Organization Name} will be able to create and/or save jobs and/or generate private investment.

Jobs Created	Jobs Saved	Private Investment
{Text Field}	{Text Field}	{Text Field}

2. Please identify the basis for the estimated number of jobs that will be created or saved for your organization? {Text Field}

3. What types of private investment are likely to be generated? {Text Field}

4. Please describe the timeframe associated with the jobs and private investment identified in the table above: {Text Field}

5. Are there other ways that this project will benefit your business or organization?): {Text Field}

3. 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} 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 {Signature Field}

Name and title of beneficiary organization authorized representative: {Name} {Title}

Date: {Date Field}

4. 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 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 {Signature Field}

Name and title of beneficiary organization authorized representative: {Name} {Title}

Date: {Date Field}

Instructions for the ED-900B – Beneficiary Information Form

This form must be completed as provided by EDA’s policies and at a minimum 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.

1. General Information

1. Enter the title of the proposed EDA project and the lead applicant

2. Enter the name of the organization that is a “committed beneficiary” in the application for EDA assistance. Note that a separate form must be completed by each identified “committed beneficiary.”

3. Enter the address of the organization in #2.

4. Please characterize the main industry/field for the beneficiary organization. A searchable list of North American industries is available at http://www.census.gov/eos/www/naics/.

2. Estimated Impact of the EDA Investment

This section should be completed by each beneficiary of the proposed project that has been identified as “committed” by the EDA applicant.

For the purposes of completing the table in this section

• Jobs created means that as a direct result of this project, these jobs will be generated.

• Jobs saved means that without this project, the jobs listed here would be lost.

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.

3. Provision of Data on the EDA Investment

This section should be completed by each beneficiary of the proposed project that has been identified as “committed” by the EDA applicant.

4. Assurances by Beneficiary that is an “Other Party”

Any beneficiary that meets the definition of “Other Party” that will create or save 15 or more permanent jobs as a result of the EDA investment, must have an authorized representative for the beneficiary “Other Party” organization complete Section D.