Business Hardship Application
Applicant Information
Name of Applicant
*
Prefix
First Name
Middle Name
Last Name
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
E-mail of Applicant
*
example@example.com
Applying as
*
Sole Proprietor
Partnership
Corporation
Non-Profit
How many employees do you have including yourself? (2 part-time = 1 full time)
*
Business Information
Business Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Additional business address location(s): If none - leave blank
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
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What hardship are you facing in your business?
*
Please provide a brief overview of your small business. Include a summary about the business including information about products and/or services, operation hours and days, and the target markets it serves.
*
Is the business currently operating?
*
Yes
No
If no, what date did business close?
-
Month
-
Day
Year
Date
If yes, Please provide a brief description of the plan to operate during the next six months.
*
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Do you have insurance that will help to cover your losses?
Yes
No
Are any of these Payment Deferments in process or completed.
*
Rows
Response
Deferred Business Installment Debt
Yes
No
Deferred Business Credit Card Debt
Yes
No
Utilities
Yes
No
Rent or Mortgage Payment
Yes
No
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Amount Requested and Documentation
Amount Requesting
*
How will you use the Funds
*
Rent/Lease
Utilities
Emergency Repairs
Other
Application of Funds – Required Documentation Please provide receipts and supporting documentation for all costs the requested funds will cover. The following documentation is required based on the type of assistance being requested: 1. Utilities Assistance – Copy of shut-off notice or documentation showing late/unpaid balances. 2. Rent/Lease Assistance – Copy of late notice or eviction notice from landlord/property manager. 3. Emergency Repairs – At least one estimate from a licensed contractor, including a detailed scope of work and pricing for the repairs. Incomplete applications or missing documentation may delay review and processing of your request.
*
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I attest that the information provided in this application herein are true and correct.
*
Yes
Signature
*
Submit my application
Submit my application
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