Weld County Business Recovery Program Round 2

1. Name*

2. Phone*

3. Email*

example@example.com

4. Business Name (legal registered name)*

5. Business DBA Name (*if same as legal registered name, enter again)*

6. Street Address *

7. Municipal Business/Use or Sales Tax License Number (for verification purposes). Enter “None” if your business doesn’t have one.*

8. Type of Business Entity. (Select 1 option)*

8-A: Non-Profits ONLY: Please describe the programmatic support that you have, or intend to give, that relates to the recovery of you local economy from COVID-19 related hardship to business in your area.

9. What year was your business formed?*

10. Category of Business. (Select 1 option)*

11. My business is: (select 1 option)*

NOT home-basedHome-based

12. My business locations: (select 1 option)*

Only 1 location in Weld CountyMultiple locations, but only in Weld CountyMultiple locations in and outside of Weld County

13. I understand I am applying for the Weld County Business Recovery Program. I have read and understand the program’s rules and eligibility requirements BEFORE completing this application. (Select 1 option)*

AgreeDo not agree

14. I understand I may be required to provide additional documentation to verify the responses. I enter into this application, and further, I acknowledge that if I am unable to provide additional documentation in a timely manner my application may be deemed ineligible. (Select 1 option)*

AgreeDo not agree

15. I understand for the Weld County Business Recovery Program all grants will be awarded within the eligibility requirements, published process, and to the extent of available funding. However, I further acknowledge there are likely to be more eligible applications than there will be available grants and my eligible application may not receive a grant award. (Select 1 option)*

AgreeDo not agree

16. My business is registered with the Colorado Secretary of State and is organized in the State of Colorado. (Select 1 option)*

YesNo

17. My business has a current certificate of good standing from the Colorado Secretary of State. (Select 1 option)*

YesNo

18. My business’s principal place of business is at a physical address within Weld County, Colorado. (Select 1 option)*

YesNo

19. The physical address I will later enter into this application is not a post office box, private mail box at a mailing service center/store, or a virtual mailbox. (Select 1 option)*

TrueFalse

20. My business is a not 501(c)3 nonprofit corporation. (Select 1 option)*

TrueFalse

21. My business is not a lobbying organization. (Select 1 option)*

TrueFalse

22. My business is not a government organization. (Select 1 option)*

TrueFalse

23. My business was in operation on or prior to February 1, 2020. (Select 1 option)*

TrueFalse

24. My Business is located in:*

25. My business is located in Unincorporated Weld County.*

TrueFalse

26. I am an equity owner of the business applying for assistance and I reside in Weld County, Colorado. (Select 1 option)*

TrueFalse

27. If awarded a grant, I affirm we intend our business to be solvent and in operation for at least 90 days from the date of grant award. (Select 1 option)*

YesNo

28. None of the business’s owners, spouses or immediate family members are employees or elected officials within Weld County. (Select 1 option)*

YesNo

29. My business was forced to close temporarily due to the public health orders related to the COVID-19 public health crisis. (Select 1 option)*

YesNo

29-A. Date range your business was temporarily closed.*

30. My business was forced to dramatically limit operations due to the public health orders related to the COVID-19 public health crisis. (Select 1 option)*

YesNo

31. Number of employees or Full Time Equivalents (FTE) my business had in June, 2019. (If none, enter “0”)*

32. Number of employees or Full Time Equivalents (FTE) my business had in February, 2020. (If none, enter “0”)*

33. Number of employees or Full Time Equivalents (FTE) my business had in April, 2020. (If none, enter “0”)*

34. Number of employees or Full Time Equivalents (FTE) my business had in June, 2020. (If none, enter “0”)*

35. Describe your business and how it generates revenue.*

36. Describe the hardship caused to your business due to the COVID-19 virus.*

37. The amount my business has spent on COVID-19 mitigation measures in 2020. (Consider expenses such as PPE, screens, floor decals, signage and other similar expenses). Enter "0" if amount is zero.*

38. Describe your business’s plan for continued viability through to January, 2021 and beyond.*

39. Describe how your business intends to use grant funds, if they are awarded, from this program.*

40. My business’s verifiable gross revenues from March 1, 2019 - September 30, 2019. If your business was not open in 2019, please enter "0".*

40-A. Upload supporting documentation for the items listed in question 40. Required documentation includes a Profit & Loss statement for the period of March 1, 2019 - September 30, 2019 from an accounting software. *

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41. My business’s verifiable gross revenues from March 1, 2020 - September 30, 2020.*

41-A. Upload supporting documentation for the items listed in question 41. Required documentation includes a Profit & Loss statement for the period of March 1, 2020 - September 30, 2020 from an accounting software. *

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42. Between March 1, 2020 and September 30, 2020, my business performed which of the following? (Check all that apply). NOTE: While your business may have been temporarily closed during this period of time, was your business paying bills like rent and utilities? Was your business providing paychecks or taking care of other business operations/transactions between March 1, 2020 and September 30, 2020?*

Continued operations/open to public, even on a limited basisReceived revenues for goods delivered and/or services performedIssued payroll checksPaid Rent or mortgagesUsed/installed COVID 19 mitigation measures such as PPE, screens, floor decals,signage, etc.Other

43. Please list the SPECIFIC expenses you are reporting per the program guidelines (building modifications, PPE, testing supplies, rent assistance, etc.). For items to be considered eligible for the program, receipts or invoices supporting the request must be provided below. *

43-A. Upload all supporting documentation for the items listed in question 43. Required documentation includes receipts for expenses, invoices for expenses, or other appropriate proof of payment. Expenses reported without clear supporting documentation may not be eligible for the Weld County Business Recovery Program. *

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44. Upload your business's completed and valid W-9 form.*

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Operating statement for the current year and prior year
- Dates for operating statements should begin March 1,2020 and September 30, 2020.
  - Note: If it is easier to submit revenue and expenses through the last closed calendar month or reporting period, you may select an alternate date, such as May 31, 2020. Please be consistent and use the same date for reporting 2020 and 2019 revenues and expenses.
- If you have an accountant, QuickBooks or other system that tracks revenue and expense, you can pull your information from those resources to complete this section.
Note: If you do not have the above information in a readily available format, you can pull together your total revenues and total expenses from the following items:
- Bank statements
- PayPal/eBay/Amazon or other similar companies for revenue balances that have not been received by your bank
- Point of Sale (POS) reports for revenue figures in place of other sources above
- Credit card charges to capture expenses that were not paid by your bank account
- Any other reliable sources showing revenues and expenses that are not listed

Step 1: Provide the total revenues and total expenses for the current year beginning March 1st:

March 1, 2020 to September 30, 2020* (Enter Positive Amounts):

*Note: Please be consistent and use the same date for reporting 2020 and 2019 revenues and expenses.

Total Revenue Received:*

Total Expenses Paid:*

Step 1: Net Income/Loss

Step 2: Provide the total revenues and total expenses for the prior year same time period as above:

March 1, 2019 to the day September 30, 2019* (enter positive amounts):

*Note: Please be consistent and use the same date for reporting 2020 and 2019 revenues and expenses.

Total Revenue Received:*

Total Expenses Paid:*

Step 2: Net Income/Loss

Step 3A: OPERATING COSTS: “Operating Costs” means rent or mortgage payments (as applicable), utility costs, vendor payments to support the Grantee’s operations, but specifically excluding COVID related expenses. Operating Cost may include payroll, but only to the extent the Grantee has not applied for, or received, PPP funding from the CARES Act program and to the extent not included in COVID related expenses.

Note: This section will help Grantees determine the amount of CARES Act Grant Funding the Grantee is eligible for under the Weld County Business Recovery Program. Please retain all supporting documentation as the information will need to be submitted with the application and the information may be requested by the County or U.S. Treasury if additional audits of the program are required. These expenses are costs and expenses that the Grantee incurred between March 1, 2020 and the September 30, 2020. The Grantee must be able to present these documents if audited.

Note: Total Operating Costs specifically excludes any COVID related expenses which are documented below.

Rent or Mortgage Payment:*

Utility Costs:*

Vendor Payments:*

Applicable Payroll Expenses (*payroll expenses may only be included if you have not applied for or received PPP funding and the payroll expenses are not included in COVID related expenses below):*

Step 3: Operating Costs

Step 3B: COVID Related Expenses: “COVID related expenses” means costs and expenses to the Grantee that are directly related to the COVID-19 pandemic and may include cleaning supplies, extra staffing costs to maintain social distancing or other public health measures, and expenses for personal protection equipment (“PPE”) among other costs and expenses. Note: Payroll costs may be included, but to the extent the Grantee has applied for, or received, Paycheck or Payroll Protection Plan (“PPP”) funding from the CARES Act program, those additional revenues should be reported in Section D.

Note: The Grantee may not include expenses in Operating Costs under the COVID Related Expenses or vice versa; to do so would double count costs. Double counting will be considered a material breach of the Grant Agreement and in such event the County may require the repayment of the Grant Award Amount in full.

Do NOT include any expense item in both A & B.

PPE Expenses:*

Cleaning Supplies:*

Signage Expenses:*

Additional Payroll Expenses:*

Other COVID Related Expenses:*

Step 3B: Total COVID Related Expenses

Step 3C: Revenue (Excluding COVID or CARES Act Assistance)

Note: This figure should be the total income or revenue to the Grantee beginning March 1, 2020 thru September 30, 2020, or other date identified by the Grantee in the operating statement. In addition, Total Income/Revenue should EXCLUDE COVID or CARES Act Assistance or Grant Revenue which is accounted for in Section D below so those funds are not counted twice.

Total Income/Revenue:*

Step 3D: COVID OR CARES ACT ASSISTANCE: This section should include all loans and/or other grant funding or relief the Grantee has applied for, is currently applying for, and/or received relating to assistance during the COVID pandemic, whether federally funded through the CARES Act or another federal program such as FEMA, or unrelated third party grants for COVID relief.

PPP Loan/Grant:*

Pandemic Unemployment Insurance/Benefits:*

State CARES Act Funding:*

Other Local Government CARES Act Funding:*

Local Small Business Emergency Grant:*

Other COVID Assistance:*

Step 3D: Total COVID or CARES Act Assistance:

Please list the first and last names of the individuals who each own 20% or more of this business. (If none input "none").*

45. In submitting this application, I, the undersigned, hereby certify that: (1) I am authorized to bind the applicant; (2) the applicant does or will comply with the Requirements and Criteria set forth below; (3) the applicant understands and agrees that failure to comply with the Requirements and Criteria below will disqualify the applicant from award of grant funds, and if any funds have been disbursed to the applicant, the applicant agrees to immediately repay such funds to the City. (Select 1 option)*

AgreeDo not agree

46. Applicant agrees to use grant or loan funds only for the legitimate expenses of the business and in general alignment with applicant’s response to item on this form. A few examples of eligible uses includes commercial rent, payroll expenses, business supplies & materials, materials purchased for the mitigation of COVID-19 response and expenses incurred for compliance with public health orders (e.g., PPE, temporary barriers, signage, temperature check stations, etc.). (Select 1 option)*

AgreeDo not agree

47. Applicant agrees to provide to Upstate Colorado Economic Development a grant report, specifically including copies of proof of payments for legitimate business expenses (receipts, invoices, etc.), on or before December 15, 2020. (Select 1 option)*

AgreeDo not agree

48. Applicant agrees to and grants permission for Upstate Colorado Economic Development to use their name and their business’s names, photographs, voices, video recordings, personal appearances and likenesses in connection with the reporting and promotion of this program. Applicant waives any claims to royalty, right, or remuneration for such use. Applicant agrees such information may be used for marketing and other purposes. Further, Applicant understands that identification of company will be included in public reporting. (Select 1 option)*

AgreeDo not agree

49. Because the internet consists of multiple interconnected networks and end points (e.g., websites and other content providers) which are not directly connected to Upstate Colorado’s server network, the applicant agrees to indemnify and hold harmless Upstate Colorado Economic Development, its vendors and participating government entities from any failures of the internet, electronic equipment or software used in the submission of this grant application. (Select 1 option)*

AgreeDo not agree

50. CERTIFICATION: I, the primary applicant listed in this application, hereby CERTIFY all statements in this application are true and complete. I agree and acknowledge any misstatements or material omissions herein is grounds for immediate payback in full of any funds granted through this program, and that Weld County or its assigns may use any means necessary to collect this debt. (Select 1 option)*

AgreeDo not agree

Electronic Signature Required

End of form.

Don't forget to attach all files before submitting this form.

Weld County Business Recovery Program

Signature

Weld County Business Recovery Program

Applicant Information (Primary Applicant & Contact)

Affirming Grant Program Structure

Verification of Eligibility

Business Information

Business Interruption Determination

Step 1: Provide the total revenues and total expenses for the current year beginning March 1st:

Step 2: Provide the total revenues and total expenses for the prior year same time period as above:

Step 3C: Revenue (Excluding COVID or CARES Act Assistance)

Applicant Agreements & Affirmations