Hazard Pay Grant Application

All funds recieved are subject to an audit by the City of Federal Way, the Washington State Auditor, or the United States Department of Treasury.

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Agent/Representative Name *

Store # *

Organization/Company Name *

Business Phone *

Contact Phone *

Email Address *

Mailing Address *

City *

State *

Zip Code *

Physical Location *

Federal Way Business License Number *

Number of Employees Covered *

Total Hours Worked *

Pay Roll Start Date *

Pay Roll End Date *

Total Dollar Amount Requested *

Agent/Representative Digital Signature (Type Name) *

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