NeighborImpact COVID-19 Small Business/Microenterprise Grant Program Application

NeighborImpact COVID-19 Small Business/Microenterprise Grant Program Application - Madras/Jefferson County Program

Puede traducir este formulario con la bandera de idiomas en la esquina superior
1. Business Applicant
A. Registered Business Name: *
B. DBA:
C. Tax ID:
D. Years in Business (provide opening date if less than 2 years):
E. Business Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
F. Phone Number: *
G. Email Address: *
example@example.com
H. Number of Full-Time Equivalent (FTE) Employees in Jefferson County as of 3/1/20:
I. Current Number of Full-Time Equivalent (FTE) Employees:
FTE Definition: Full-time equivalent (FTE) is a calculation of an employee's scheduled hours divided by a full-time workweek. Employees who are scheduled to work 40 hours per week are 1.0 FTEs. Employees scheduled to work 20 hours per week are 0.5 FTEs. FTE calculations are about hours worked rather than number of employees. You could have four employees and only one FTE. Four 0.25 employees would be 1.0 FTE. Steve, Jose, Karen and Joan could each work 10 hours per week and the total would be 40 hours worked, or one FTE based on a 40-hour workweek.
J. Is this a Woman-Owned Business?

Yes No
K. Is this a Minority-Owned Business?

Yes No
L. Business Owner Name:

First Name Last Name
M. Business Owner Phone Number:
N. Business Owner Email Address:
example@example.com
O. Business Owner Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
P. Co-Owner Name:

First Name Last Name
Q. Co-Owner Phone Number:
R. Co-Owner Email Address:
example@example.com
S. Co-Owner Home Address:

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
2. Grant Request
A. Click below to indicate if the applicant business is a Small Business or a Microenterprise.

Small Business Microenterprise
Small Business Definition: A business that is independently owned and operated and which is not dominant in its field of operation and in conformity with specific industry criteria defined by the Small Business Administration (SBA).

Microenterprise Definition: A commercial enterprise that has five or fewer employees, one or more of whom owns the enterprise.
B. Number of Low- or Moderate-Income FTE Jobs that will be retained:
Job retention number must match the information provided within Attachment A, Job Creation/Retention Form
C. Grant Funds Requested ($2,500 per FTE retained, up to $20,000 maximum for a small business; a maximum of $10,000 for a microenterprise):
3. Please answer the following questions
A. Provide a summary of the impacts of the COVID 19 public health emergency on your business, and how these impacts have affected your business/business plan.
B. Describe specific gaps in your operating budget resulting from the COVID emergency. Note that financial documents must be provided that demonstrate the operating budget gaps or deficits that have resulted from the COVID emergency.
C. Provide a summary of how grant funds will be used, and how the business will remain viable and maintain jobs for at least 6 months.
D. Have you or your business received COVID-related assistance (grants or loans) from other funding sources? *

No Yes
4. Additional Required Documents:
A. Upload a W-9 form for your business

Cancel of
Download a blank W-9 Form
B. Upload Financial Statements for 2018 and 2019 – Income statements and Balance Sheets* (Preferred file formats are PDF and JPG/GIF)

* If the applicant business was opened after January 1, 2019, then only 2019 Financial Statements must be submitted
Cancel of
C. Upload Financial Statements for 2020 – Income statement and Balance Sheet (Preferred file formats are PDF and JPG/GIF)

Cancel of
D. Optional: Upload any additional items to demonstrate the business’s need for assistance and/or plan to sustain operations with the grant funds.

Cancel of
E. I certify that the submitted documents and information is accurate and is subject to verification by NeighborImpact, the City of Madras, and/or Business Oregon.
Signature of Business Owner

Clear
Date

Month Day Year
Date
Should be Empty:

NeighborImpact COVID-19 Small Business/Microenterprise Grant Program Application - Madras/Jefferson County Program