Winnebago County Restaurant COVID-19 Unemployment Insurance Relief

If you are a previous applicant, you need to fill out the top section of section 1 and all of section 2. You will also need to upload the required documents for section 3.

If you have not applied previously, you will need to fill out the entire application.

Restaurant Legal Name*

D/B/A*

Restaurant Owner Full Name*

First NameLast Name

Grant Contact Full Name*

First NameLast Name

Did you file a complete application for Round 1 or Round 2 of the Restaurant Relief Grant?*

YesNo

If yes, proceed to Section 2. If no, fill out the rest of section 1.

Restaurant Location Address

Restaurant Mailing address, if different

Restaurant Phone

Please enter a valid phone number.

Restaurant Owner Email*

example@example.com

Restaurant Owner Mailing address*

Restaurant Owner Phone*

Grant Contact Email

example@example.com

Grant Contact Mailing address

Grant Contact Phone

Business FEIN or equivalent

Business NAICS Code from tax return

Date Business Established

Type of Entity (Corporation, Partnership, Sole Proprietor)

This sectiion must be completed by all applicants. By Signing Below, you make the following representations and certifications on behalf of the restaurant:

I, Authorized Agent* on behalf of Restaurant Legal Name* , hereby declares and acknowledges the following:

The principal place of business for Restaurant Legal Name* is located within the geographical boundaries of Winnebago County, Illinois.
As such, Restaurant Legal Name* acknowledges that it is subject to the laws and regulations of Winnebago County, Illinois, and undertakes to comply with all applicable legal and regulatory obligations therein.
Furthermore, Restaurant Legal Name* complied with the indoor dining closure mandates enacted by the State of Illinois for Q1 and Q2 of 2021 via Executive Orders 2021-1, 2021-2, 2021-3, 2021-4, and 2021-5, 2021-6, 2021-9, 2021-10
Therefore, as a result of complying with indoor dining closure mandates in Q1 and Q2 of 2021, Restaurant Legal Name* experienced an increase in unemployment benefit charges.
Restaurant Legal Name* incurred/will incur a higher rate of state unemployment taxes in 2022, 2023 and 2024, as a result of the higher unemployment benefit charges in Q1 and Q2 of 2021.

If Yes, Checklist of Documents to Upload

State Unemployment Tax Reports for Q3 and Q4 2024Proof of payment for State Unemployment Taxes for Q3 and Q4 2024

If No, Checklist of Documents to Upload

W-9 for Restaurant2021 Restaurant Tax ReturnIDES form BEN-118 – Statement of Benefit Charges for Q1 and Q2 2021IDES Rate Determination letter for 2022, 2023, and 2024State Unemployment Tax Reports for 2022, 2023 and 2024Proof of payment of State Unemployment Taxes for 2022, 2023, and 2024

File Upload*

Additional Comments

Signature*

Date*

Date

Full Name of Authorized Agent*

Title*

Winnebago County Restaurant COVID-19 Unemployment Insurance Relief

Section 1

Section 2

Section 3

Disclosures