Request for Distribution of County CARES Act Funds Application Form

Request for Distribution of County CARES Act Funds

Application Form

For Internal Use Only

Rows	Phase 1	Phase 2	Phase 3
App. No. ________________________________

We encourage you to fully read the instructions, guidance, and FAQs and submit your application for any reimbursements meeting those criteria. Please be as specific and detailed as possible in your application about how your request meets the guidelines.

Click on the document title below to read or download:

Application Instructions

Guidance

FAQ's
Introduction: Full instructions for completion of this Application are included at the end of this application. Failure to submit required information in order to evaluate the Application and make a funding award decision may result in denial of an Application and an award of funds.
- 1. Legal Name*
  
  First NameLast Name
- 2. Mailing Address*
- 3. Primary Contact*
  
  First NameLast NameTitle
- 4. City*
- 5. County*
- 6. State*
- 7. Zip*
- 8. Business Phone Number*
  
  Area CodePhone Number
- Business Phone Number
  
  Area CodePhone Number
- 9. Applicant Type
  
  CityTown/Township/VillageSchool DistrictCounty HospitalHospital DistrictFire Protection DistrictAmbulance DistrictCity/County LibraryMunicipal CorporationPolitical CorporationOther
- If choosing other, list entity type here.
- Applicant Type
  
  Sole ProprietorPublic Corporation (General)LLCLPLLPClose CorporationProfessional CorporationNonprofit CorporationForeign Entity
- If choosing Foreign Entity, list entity type here.
- 10. Fax Number
  
  Area CodePhone Number
- 11. Email
  example@example.com
- 12. Tax Identification Number
- 13. Is the Applicant located within the County?*
  
  YesNo
- 14. Does the Applicant have locations, facilities, offices, operations, divisions, branches, or offices located outside the County? (If no, skip to Section A.16.)*
  
  YesNo

15. If the answer to Item A.14 is "Yes," list the locations by address and county of the other segments of the Applicant.
16. In the space below, describe the general business operations of the Applicant, such as the services or goods provided, and the purpose or mission of the Applicant. *

1. If Applicant is local government/public entity, list the chief executive and elected officials of the governing body by name and title. If Applicant is a private entity, list the name, title, and ownership percentage of all owners of 20% or more equity of the Applicant.*

Rows	First and Last Name	Title	Ownership Percentage
Person 1
Person 2
Person 3
Person 4
Person 5

2. Is the Applicant or any owner of the Applicant presently suspended, debarred, proposed for debarment, declared ineligible, voluntarily excluded from participation in this transaction by any Federal department or agency, or presently involved in any bankruptcy?*

YesNo
3. Has the Applicant, any owner, or any business owned or controlled by any of them, obtained a direct or guaranteed loan from a federal or state agency that is currently delinquent or has defaulted in the last 7 years?*

YesNo
4. Is the Applicant, or any individual owning 20% or more of the equity subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges (other than traffic citations) are brought in any jurisdiction, presently incarcerated, or on probation or parole?*

YesNo
5. Within the last 5 years, for any felony, has the Applicant or any owner: (a) been convicted; (b) pleaded guilty; (c) pleaded nolo contendere; (d) been placed on pretrial diversion; or (e) been placed on any form of parole or probation (including probation before judgement)?*

YesNo
If the answer to Items B.2.; B.3.; B.4.; or B.5. is "Yes," the Application will be denied and funds will not be awarded.

1. Medical Expenses
(a) Is Applicant requesting funds for medical expenses (as described Paragraph E.1 of the Instructions linked on page 1)?*

YesNo
(b) State the amount of funds requested.

(c) If the answer to Item D.1.(a) is "Yes," in the space below, describe the category of expenditure (e.g. COVID-19-related expenses of public hospitals, clinics, and similar facilities) and proposed use of funds, and the itemized amount requested. Attach supporting documentation for the request. Attach additional pages if necessary.

Rows	Description	Amount
Item 1
Item 2
Item 3
Item 4

Click the button below to upload D.1.(c). supporting documentation, if necessary.

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(d) Explain in detail the intended use and how the intended use meets the criteria for a "necessary expenditure" under CARES Act (as described Paragraph B of the Instructions linked on page 1). Attach supporting documentation. Attach additional pages if necessary.
Click the button below to upload D.1.(d). supporting documentation, if necessary.

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2. Public Health Expenses
(a) Is Applicant requesting funds for public health expense (as described Paragraph E.2 of the Instructions linked on page 1)?*

YesNo
(b) State the amount of funds requested.

(c) If the answer to Item D.2.(a) is "Yes," in the space below, describe the category of expenditure (e.g., Expenses for acquisition and distribution of medical and protective supplies) and proposed use of funds, and the itemized amount requested. Attach supporting documentation for the request. Attach additional pages if necessary.

Rows	Description	Amount
Item 1
Item 2
Item 3
Item 4

Click the button below to upload D.2.(c). supporting documentation, if necessary.

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(d) Explain in detail the intended use and how the intended use meets the criteria for a "necessary expenditure" under the CARES Act (as described Paragraph B of the Instructions linked on page 1). Attach supporting documentation.
Click the button below to upload D.2.(d). supporting documentation.

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3. Payroll expenses for public safety, public health, health care, human services, and similar employees whose services are substantially dedicated to mitigating or responding to the COVID-19 public health emergency
(a) Is Applicant requesting funds for payroll expenses for public safety, public health, health care, human services, and similar employees whose services are substantially dedicated to mitigating or responding to the COVID-19 public health emergency?*

YesNo
(b) State the amount of funds requested.

(c) If the answer to Item D.3.(a) is "Yes," in the space below, describe the category of expenditure (e.g., payroll expenses for the public safety employees whose services are substantially dedicated to mitigating or responding to the COVID-19 public health emergency) and proposed use of funds, and the itemized amount requested. Attach supporting documentation for the request. Attach additional pages if necessary.

Rows	Description	Amount
Item 1
Item 2
Item 3
Item 4

Click the button below to upload D.3.(c). supporting documentation, if necessary.

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(d) Explain in detail the intended use and how the intended use meets the criteria for a "necessary expenditure" under CARES Act (as described Paragraph B of the Instructions linked on page 1). Attach supporting documentation.
Click the button below to upload D.3.(d). supporting documentation.

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4. Expenses of actions to facilitate compliance with COVID-19-related public health measures (as described Paragraph E.4 of the Instructions linked on page 1.)
(a) Is Applicant requesting funds to facilitate compliance with COVID-19-related public health measures?*

YesNo
(b) State the amount of funds requested.

(c) If the answer to Item D.4.(a) is "Yes," in the space below, describe the category of expenditure (e.g., expenses for delivery to residents) and proposed use of funds, and the itemized amount requested. Attach supporting documentation for the request. Attach additional pages if necessary.

Rows	Description	Amount
Item 1
Item 2
Item 3
Item 4

Click the button below to upload D.4.(c). supporting documentation, if necessary.

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(d) Explain in detail the intended use and how the intended use meets the criteria for a "necessary expenditure" under CARES Act (as described Paragraph B of the Instructions linked on page 1). Attach supporting documentation.
Click the button below to upload D.4.(d). supporting documentation.

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5. Expenses associated with the provision of economic support in connection with the COVID-19 public health emergency (as described Paragraph E.5 of the Instructions linked on page 1).
(a) Is Applicant requesting funds that will be used for the provision of economic support in connection with COVID-19?*

YesNo
(b) State the amount of funds requested.

(c) If the answer to Item D.5.(a) is "Yes," in the space below, describe the category of expenditure (e.g., expenditures related to the provision of grants to small businesses to reimburse the costs of business interruption caused by required closures) and proposed use of funds, and the itemized amount requested. Attach supporting documentation for the request. Attach additional pages if necessary.

Rows	Description	Amount
Item 1
Item 2
Item 3
Item 4

Click the button below to upload D.5.(c). supporting documentation, if necessary.

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(d) Explain in detail the intended use and how the intended use meets the criteria for a "necessary expenditure" under CARES Act (as described Paragraph B of the Instructions linked on page 1). Attach supporting documentation.
Click the button below to upload D.5.(d). supporting documentation.

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6. Any other COVID-19-related expenses reasonably necessary to the function of government that satisfy the Coronavirus Relief Fund's eligibility criteria.
(a) Is Applicant requesting funds for purposes that are not listed Items 1-5, above, that otherwise satisfy the Coronavirus Relief Fund eligibility criteria?*

YesNo
(b) State the amount of funds requested.

(c) If the answer to Item D.6.(a) is "Yes," in the space below, describe the category of expenditure and proposed use of funds, and the itemized amount requested. Attach supporting documentation for the request. Attach additional pages if necessary.

Rows	Description	Amount
Item 1
Item 2
Item 3
Item 4

Click the button below to upload D.6.(c). supporting documentation, if necessary.

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(d) Explain in detail the intended use, and how the intended use meets the criteria for a "necessary expenditure" under CARES Act (as described Paragraph B of the Instructions linked on page 1). Attach supporting documentation.
Click the button below to upload D.6.(d). supporting documentation, if necessary.

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NOTE: The page below must be printed and notarized. If submitting this Application electronically, the notary page may be submitted separately, but it must be received by the deadline.
Notary Page: To print this form, mouse over form, click the printer icon to initiate printing. The down arrow will allow you download this form to your computer.
Once you have downloaded or printed the Notary Page above, you have reached the end of this Application.
- Next, click the "Save" button below to save the Application.
- After saving, click "Print Form" to print a copy of the Application for your records.
- To send your Application for funding consideration, click "Submit."
Please direct questions to the Table Rock Lake Chamber of Commerce at 417-739-2564 or sthomas@visittablerocklake.com.
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