Form Center

2. Instructions to fill out Grant!
   These are instructions to fill out the form. aldkfalkjfd alj;alk falkdf ;akk;al dfkaj flkk;lasj ;lkaj ;alkfd;adf; liaj;odif ja;oifja;lkdjf aikdfj ;aoidjf o;aijfoia faoijf aidjf opaisjdoai;j faoidjf oaidjf aoijdfaoidj faoijdf oaidjf paoidjf opaiopa ijfpoaidj paoidj paoijfaop ijfpaoidjf oiasjf paikjfcpaoi jfapoisjfd paoijfdpaois jpaoijcpaoij poiaokfpoiajpoiasjpoiajpoiakjpcoiakjpoicajpoicjapoij pidakjo iajpaoik jopiaksj oksj sioakjpoi jdapoif apoidkuf pufpaoidkufs paoisjcpaoiskjcoia jscpaoiskjc !
4. First Name*
5. Last Name*
7. Phone*
8. Mobile Phone*
10. Email*
12. Application Qualifications
14. Has the business or a listed owner ever been involved in a bankruptcy or insolvency proceeding?*
    -- Select One --YesNo
16. Does the business or a listed owner have any outstanding judgments, tax liens, or pending lawsuits against them?*
    -- Select One --YesNo
18. In the past year, has the business or a listed owner been convicted of a criminal offense committed during and in connection with a riot or civil disorder or other declared disaster, or ever been engaged in the production or distribution of any product or service that has been determined to be obscene by a court of competent jurisdiction?*
    -- Select One --YesNo
20. Is the business or a listed owner delinquent on any Federal taxes, direct or guaranteed Federal loans (SBA, FHA, VA, student, etc.), Federal contracts, Federal grants, or any child support payments?*
    -- Select One --YesNo
22. Is the applicant or any listed owner currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans? *
    -- Select One --YesNo
24. Regarding you or any joint applicant listed: are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction; b) have you been arrested in the past six months for any criminal offense; c) for any criminal offense - other than a minor vehicle violation - have you ever: 1) been convicted, 2) plead guilty, 3) plead nolo contendere, 4) been placed on pretrial diversion, or 5) been placed on any form of parole or probation (including probation before judgement)?*
    -- Select One --YesNo
26. Have you been approved for the Paycheck Protection Program?*
    -- Select One --YesNo
28. Have you been approved for an Economic Injury Disaster Loans?*
    -- Select One --YesNo
30. Have you received any form of private, public of federal financial support during the Covid-19 Pandemic?*
    -- Select One --YesNo
32. Business Information
34. Legal Business Name*
36. DBA Business Name
38. FEIN*
39. NAICS Code
40. Industry
42. Business Physical Address*
44. City*
45. State*
46. Zip*
48. County*
50. Mailing Address*
52. City*
53. State*
54. Zip*
56. Number of Years in Business*
57. Number of FTEs*
58. Number of Part-Time Employees*
62. Grant Request Information
64. Amount requested - Amount not guaranteed*

    1. 1,000
    2. 2,000
    3. 3,000
    4. 4,000
    5. 5,000
66. How has Covid-19 affected your business?*
68. What is the purpose of the funds?*
70. IRS W-9 with October 2019 revision date
72. Most recent balance sheet or balance sheet for past quarter*
74. Digital Signature
76. I Agree:*

    1. On behalf of the organization(s) for which I am submitting this information, I represent that the information submitted in this application is true and correct, and I agree that it may be relied upon
78. First Name*
79. Last Name*
81. Title*
83. Business Name*
85. Date*
Leave This Blank:


87. 1. Receive an email copy of this form.
88. Email address

    This field is not part of the form submission.

89. Submit

* indicates a required field