Thank you for your interest in the Small Business Emergency Assistance Grant. At this time, we are no longer accepting applications. However, you may contact the following organizations who may help you with funding options in the future as they become available:

Hartford Emergency Small Business Emergency Assistance Grant Program

Please make sure all required fields are completed. Prepare and verify your documents for upload by making sure you can view them on your device before you upload them. If you have any questions regarding how to complete this form, please contact a list of available partners HERE. Should you have a technical problem submitting the form, please email support@hartfordgrant.com. This grant application process will close on Monday, May 11th at 6:00 p.m. Google Chrome browser is recommended to avoid technical problems.

Asegúrese de completar todos los campos obligatorios. Prepare y verifique sus documentos para cargarlos asegurándose de que pueda verlos en su dispositivo antes de cargarlos. Si tiene alguna pregunta sobre cómo completar este formulario, comuníquese con una lista de socios disponibles AQUÍ. Si tiene algún problema técnico al enviar el formulario, envíe un correo electrónico a support@hartfordgrant.com. Este proceso de solicitud de subvención se cerrará el lunes 11 de mayo a las 6:00 p.m. Se recomienda el navegador Google Chrome para evitar problemas técnicos.


Section 1: Applicant Information

Business Name: *
Business Address - Street Address: *
Business Address - City: *
Business Address - State: *
Business Address - ZIP Code: *
Business Phone: *
Business Email: *
Date Business Established: *
Tax Identification Number(TIN): *
DUN # (optional):
Business Structure: *




Type of business: *






Briefly describe business: *
2019 Gross Revenues: *
2019 Net Profit/Loss: *
Total Number of Employess: *
Number of Women: *
Number of Men: *
Number of Minorities: *

Section 2: Owner Information

1st Owner

Owner Name: *
Owner SSN: *
Owner Phone: *
Owner Address - Street Address: *
Owner Address - City: *
Owner Address - State: *
Owner Address - ZIP Code: *
Owner Gender Identification (not required):
Owner Ethnicity (not required):

2nd Owner (not required)

Owner Name:
Owner SSN:
Owner Phone:
Owner Address - Street Address:
Owner Address - City:
Owner Address - State:
Owner Address - ZIP Code:
Owner Gender Identification (not required):
Owner Ethnicity (not required):

Section 3: Underwriting Concerns

Have you applied for any funding from Federal Programs, (PPP or SBA), State of CT, HEDCO, LISC or COVID-19 related support programs? *


Have you been approved or received any funding? *


If yes, how much were you awarded, from which program? How much were you awarded? From which program?
Does the Business currently owe Federal or State taxes? *


Do the Business currently owe taxes to City of Hartford? *


Is the Business currently operating? *


Has the Business suffered an economic injury (losses) due to the COVID-19 Pandemic? *


Please describe the economic injury (losses) below: *

Describe how the grant will be used, if approved

Expense/Bill 1 * Amount Actual/Estimated 1 * Documentation Provided 1 * Upload documentation file 1 *
only jpg, png, pdf and office documents are accepted
Expense/Bill 2 Amount Actual/Estimated 2 Documentation Provided 2 Upload documentation file 2
only jpg, png, pdf and office documents are accepted
Expense/Bill 3 Amount Actual/Estimated 3 Documentation Provided 3 Upload documentation file 3
only jpg, png, pdf and office documents are accepted
Expense/Bill 4 Amount Actual/Estimated 4 Documentation Provided 4 Upload documentation file 4
only jpg, png, pdf and office documents are accepted
Please provide the name, if applicable, to any organization or person who assisted you in completing this application: *

Please attach both sides of your driver's license or government issued identification: *

only jpg, png, pdf and office documents are accepted

Section 4: Responsibilities of Grantees

  1. All grant awardees will be required to complete a Grant Agreement outlining all of the Awardees responsibilities associated with the receipt of this funding.
  2. Responsibilities include, but are not limited to spending funds on items identified in the completed application, keeping receipts and making records available for audit if requested.
  3. Grantee will also be required to complete two (2) surveys on the status of their business at the three (3) month and six (6) month anniversary of the receipt of grant funds. Surveys will be distributed by Capital 4 Change by email. Please complete and return as directed. They survey are important because they will be used to determine what other resources are required to support small business activities in Hartford.

By signing this application, you certify that all the information in your application and submitted with your application is true and correct to the best of your knowledge, and you will submit truthful information in the future.

Exempt payee code (if any)
Exemption from FATCA reporting code (if any)
Disclaimer: I / We authorize Capital for Change Inc. to generate a W9 form to be submitted along with this application using my / our electronic signatures and information derived from this application. *

Business Owner Signature *

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Date: 05/20/2022

  

Business CoOwner Signature

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Date: 05/20/2022

Please make sure you click and hold while signing. A mouse is preferred. You should be seeing your signature in the box. Please review all entered information for accuracy.

Thank you for submitting your request. You will receive an email and follow up from our team.

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