Information Request Form

Fletcher Case #

Taxpayer Official Name

First NameLast Name

DBAblanks NAICS Code

Texas Taxpayer ID blanks Federal Taxpayer ID

If "Other" please indicate which Entity Type: blanks

YesNo

Phone Number (Business)

Please enter a valid phone number.Format: (000) 000-0000.

Phone Number (Office)

Please enter a valid phone number.Format: (000) 000-0000.

Email

example@example.com

Office Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

NAICS Code - blanks.

#Employees 2019 as per Q4 2019 941 blanks

#Employees 2020 as per Q4 2020 941 blanks

#Employees 2021 as per Q4 2021 941 blanks

#Employees 2022 as per Q3 2022 941 blanks

IRS 941 Forms (Q4 2020, Q4 2021, Q3 2022)

Please upload the following : IRS 941 Forms (Q4 2020, Q4 2021, Q3 2022)

YesNo

If so, upload VA Service Verification Letter

For ProfitNon Profit

PPPShuttered Venues GrantRestaurant Revilitization FundSBA Debt Relief

Please indicate the amount received if any. If not, please ignore this question.
PPP ($)blank
Shuttered Venues Grant ($)   Type a label
Restaurant Revilitization Fund ($)     Type a label
SBA Debt Relief ($)   Type a label

Narrrative: Bullet points •negative economic impact suffered by the business due to the COVID-19 pandemic (lost catering, etc.) Eligible uses must be in response to the disease itself or the harmful consequences of the economic disruptions resulting from or exacerbated by the COVID–19 public health emergency. Applicants should describe how the grant will address this economic harm and are otherwise compliant with the eligibility criteria identified above

*Info about food cost and labor cost increases

Upload entire Tax Returns 2019, 2020, & 2021

2019 Total Sales

2020 Total Sales

2021 Total Sales

Reimbursement Request

Please upload: Rent/Lease Charges for 2020,2021, and 2022 + Expenses to comply with soc-dist and + Amounts and additional documentation

For all purposes of this Agreement, the term “Confidential Information” shall collectively refer to all non-public information or material disclosed or provided by one party to the other, either orally or in writing, or obtained by the recipient party from a third party or any other source, concerning any aspect of the business or affairs of the other party or its “affiliates” (as such term is defined in Rule 12b-2 under the Securities Exchange Act of 1934), including without limitation, any information or material pertaining to products, formulae, specifications, designs, processes, plans, policies, procedures, employees, work conditions, legal and regulatory affairs, assets, inventory, discoveries, trademarks, patents, manufacturing, packaging, distribution, sales, marketing, expenses, financial statements and data, customer and supplier lists, raw materials, costs of goods and relationships with third parties. Confidential Information also includes any notes, analyses, compilations, studies or other material or documents prepared by the recipient party which contain, reflect or are based, in whole or in part, on the Confidential Information.

Notwithstanding the foregoing, Confidential Information shall not include information or material that (i) is publicly available or becomes publicly available through no action or fault of the recipient party, (ii) was already in the recipient party’s possession or known to the recipient party prior to being disclosed or provided to the recipient party by or on behalf of the other party, provided, that, the source of such information or material was not bound by a contractual, legal or fiduciary obligation of confidentiality to the non-disclosing party or any other party with respect thereto, (iii) was or is obtained by the recipient party from a third party, provided, that, such third party was not bound by a contractual, legal or fiduciary obligation of confidentiality to the non-disclosing party or any other party with respect to such information or material, or (iv) is independently developed by the recipient party without reference to the Confidential Information.

Application to File for the Texas Travel Industry Grant.