Business Relief Grant Jan 2021

Business Relief Grant

January 2021
Date *

Month Day Year
Date
Business Name *
Business Contact Person Name *

First Name Last Name
Title *
Phone Number *
Please enter a valid phone number.
Email *
example@example.com
Business Address *

Street Address

Mailing address (if different than street address)

City State / Province

Postal / Zip Code
Website
My business is located in Chippewa County *

yes no
Does your business have any tax liens as of today with the MN Secretary of State? *

Yes, I do have a current tax lien No, I do not have any tax liens
Type of business *

Full- and limited-service restaurants Cafeterias and buffets Caterers Bars Breweries with taprooms Family wineries with tasting rooms Distilleries with tasting rooms Bowling centers Gyms and fitness centers Theaters Leisure Service Agencies Other (must describe below)
Business description *
6 digit NAICS code *
You can find a shortcut to determining your NAICS code here:

https://mn.gov/deed/assets/updated_list_of_NAICS_tcm1045-460975.pdf
This is a publicly owned AND operated business venture (owned and operated by a governmental agency like a city, county, school etc) *

yes no
My business was impacted from MN Executive Order 20-99? *

yes no
To review Mn Executive Order 20-99 go to section 7. c. of the following link

https://mn.gov/governor/assets/EO%2020-99%20Final%20%28003%29_tcm1055-454294.pdf
Describe how your business has been adversely impacted by COVID and/or Executive Order 20-99 *
Did your business receive a payment from the MN Department of Revenue Covid-19 Business Relief Program? *

Yes No
For more information about the MN Department of Revenue Covid-19 Business Relief Program https://www.revenue.state.mn.us/covid-19-business-relief-payments
Did your business close or partially close due to MN Executive Order 20-99? *

Yes No
My business is operational and open for business as of January 20, 2021 *

yes no
I have the following verifiable loss in revenue between calendar year 2019 and calendar year 2020. (note: you may be required to provide proof of revenue loss if the County is audited) *

Less than 10% 11-20% 21-30% more than 30%
Did you have to lay off or reduce hours for employees between Nov 1,2020 and January 12, 2021? *

Yes No
Number of employees who were laid off or had reduced hours *
Number of employees (full or part time) as of January 1, 2021. *

less than 5 between 6-10 between 11-20 21 or more
Number of employees (full or part time) as of March 1, 2020. *

Less than 5 between 6-10 between 11-20 21 or more
If your business did not previously receive a CARES grant from Chippewa County, attach a W-9 for your business by downloading the form from the link below, save the file to your computer, fill in the form and make sure it is saved to your computer, then upload it in the below section of this application.

https://www.irs.gov/pub/irs-pdf/fw9.pdf
Attach your W-9 ( only if you did NOT receive prior CARES funding from Chippewa County) *

Cancel of
If awarded, I agree to use these funds for the following eligible expenses: *

property taxes Insurance legal fees payroll rent utilities marketing/advertising license fees accounting fees routine maintenance travel/vehicle expenses office supplies repairs to existing building and equipment
Terms and Conditions

• Grantee certifies that the submitting signature on this application has the authority to apply for this grant on behalf of the business.

• Grantee certifies that they were adversely affected by Covid-19.

• Grantee certifies that they are eligible, that they were operational prior to March 1, 2020, and that they are suffering negative impacts or costs due to COVID-19.

• Grantee certifies that the expenses claimed in this application have not been reimbursed or are not pending reimbursement from any COVID-related state or federal or local funding source.

• Grantee certifies that it is not prohibited from doing business with either the federal government or the state of Minnesota as a result of debarment or suspension proceedings.

• Grantee agrees to cooperate with Chippewa County or appropriate officials for grant auditing purposes

• Grantee agrees that Chippewa County is authorized to make all inquiries it deems necessary to verify the accuracy of the information contained herein.

• Grantee agrees to promptly notify Chippewa County if any subsequent changes would affect the accuracy of the information in this application.

• Grantee agrees that it is a crime to make a false representation for the purpose of securing this grant. The grantee declares under penalty of perjury that all information provided herein is true and correct

• Grantee indemnifies the county and agrees to repay the grant if the grant award is found to violate the guidelines set forth in this application.

• Grantee acknowledges that the IRS has stated that a government grant is not excluded from the business recipient’s gross income and is therefore taxable.

• Grantee agrees that information submitted in this application is subject to the Minnesota Data Practices Act. Information such as the business name, address, and the amount of assistance you receive is considered public data
- Grantee agrees that they will provide a MNREV185b form if requested by the County. This form will be used to verify MN Department of Revenue business relief payments.
By providing a signature in the text boxes below, grantee agrees that the applicant is electronically signing this application on behalf of the grantee and acknowledges that they have certified the above statements. *

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Month: month , Day: day 2021
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