Weld County Service Industry Relief Fund

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) *

C Corp S Corp LLC LLP PC Joint Venture Partnership

9. What year was your business formed? *

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

Restaurant/Bar Gym/Fitness Center Movie Theater Live Event Venue Entertainment Center

11. My business is not home-based: (select 1 option) *

True False

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

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

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

Agree Do 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) *

Agree Do not agree

15. I understand for the Weld County Service Industry Relief Fund 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) *

Agree Do not agree

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

Yes No

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

Yes No

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

Yes No

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) *

True False

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

True False

21. My Business is located in: *

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

True False

23. 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) *

Yes No

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

Yes No

25. My business was forced to close temporarily due to the public health orders related to the COVID-19 public health crisis issued on 11/20/20. (Select 1 option) *

Yes No

26. Date range your business was temporarily closed. *

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

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

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

30. Describe the hardship caused to your business due to the COVID-19 virus, with particular focus on restrictions put in place on 11/20/20. *

31. 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. *

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

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

34. As compared to the year 2019, what do you estimate your lost revenue to be in November and December 2020. *

35. Required documentation includes a Profit & Loss statement for the period of March 2019 - December 2019 from an accounting software. Please upload that statement here: *

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36. Required documentation includes a Profit & Loss statement for the period of March 2020 - December 2020 from an accounting software. Please upload that statement here: *

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

38. Upload all supporting documentation for the items listed in question 37. 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 Service Industry Relief Fund. *

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

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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: *

Weld County Business Recovery Program 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"). *

40. 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) *

Agree Do not agree

41. 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) *

Agree Do not agree

42. 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) *

Agree Do not agree

43. 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) *

Agree Do not agree

44. 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) *

Agree Do not agree

45. 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) *

Agree Do not agree

Electronic Signature Required

End of form.

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

Weld County Service Industry Relief Fund

Signature

Clear

Weld County Service Industry Relief Fund

Applicant Information (Primary Applicant & Contact)

Affirming Grant Program Structure

Verification of Eligibility

Business Information

Applicant Agreements & Affirmations