Section 1: Applicant Information
Business Name: *
Business Address - Street Address: *
Business Address - City: *
Business Address - State: *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Business Address - ZIP Code: *
Business Phone: *
Business Email: *
Date Business Established: *
Tax Identification Number(TIN): *
DUN # (optional):
Business Structure: *
Sole Proprietorship
Limited Liablity Corp
Corporation
Other
Business Structure:
Type of business: *
Food/Restaurant
Retail
Service
Contracting/Construction
Day Care
Other
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: *
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Owner Address - ZIP Code: *
Owner Gender Identification (not required):
I do not wish to furnish this information
Male
Female
Owner Ethnicity (not required):
I do not wish to furnish this information
Hispanic or Latino
Not Hispanic or Latino
2nd Owner (not required)
Owner Name:
Owner SSN:
Owner Phone:
Owner Address - Street Address:
Owner Address - City:
Owner Address - State:
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District Of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Owner Address - ZIP Code:
Owner Gender Identification (not required):
I do not wish to furnish this information
Male
Female
Owner Ethnicity (not required):
I do not wish to furnish this information
Hispanic or Latino
Not Hispanic or Latino
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? *
Yes
No
Have you been approved or received any funding? *
Yes
No
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? *
Yes
No
Do the Business currently owe taxes to City of Hartford? *
Yes
No
Is the Business currently operating? *
Yes
No
Has the Business suffered an economic injury (losses) due to the COVID-19 Pandemic? *
Yes
No
Please describe the economic injury (losses) below: *
Describe how the grant will be used, if approved
Please provide the name, if applicable, to any organization or person who assisted you in completing this application: *
Blue Hills Civic Association
Upper Albany Merchant’s Association
Spanish American Merchants Association (SAMA)
HEDCO Inc.
Minority Construction Council
Entrepreneurial Center, University of Hartford
Hartford Chamber of Commerce
Upper Albany Main St.
None
Please attach both sides of your driver's license or government issued identification: *
Section 4: Responsibilities of Grantees
All grant awardees will be required to complete a Grant Agreement outlining all of the Awardees responsibilities associated with the receipt of this funding.
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.
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. *