Meriden Small Business COVID-19 Emergency Relief Grant Program
Application

• Control Questions
• Basic Data
• Business Data
• Grants Data
• Funds Table
• Certifications & Sign

• Do you have 2 consecutive years of full, signed tax returns with complete schedules, no older than 2017 in PDF format? *

  Yes
  No
  
  Do you have sufficient documentation of expenses in PDF format to support the amount of funding being requested? *

  Yes
  No
  
  Do you know your business’s annual gross revenue for 2019 and the YTD gross revenue for 2020? *

  Yes
  No
  
  Do you have a DUNS number? *

  Yes
  No
  
  Primary Owner’s Household Income: *

  Number of people in Primary Owner’s household: *
  Does the business have another owner? *

  Yes
  No
  

  Secondary Owner's Household Income: *

  Number of people in Secondary Owner's household: *
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• Applicant/Owner Name: *
  Owner Social Security Number (SSN): *
  Owner E-Mail: *
  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 Cell Phone: *
  Co-Owner Name: *

  Co-Owner Social Security Number (SSN): *

  Co-Owner E-Mail: *

  Co-Owner Address - Street Address: *

  Co-Owner Address - City: *

  Co-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

  Co-Owner Address - ZIP Code: *

  Co-Owner Cell Phone: *
  Business Name: *
  Business E-mail: *
  Business Physical Address - Street Address: *
  Business Physical Address - City: *
  Business Physical 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 Physical Address - ZIP Code: *
  Is mailing address the same as physical address? *

  Yes
  No
  

  Business Mailing Address - Street Address: *

  Business Mailing Address - City: *

  Business Mailing 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 Mailing Address - ZIP Code: *
  Business Phone: *
  Alt Phone:
  Tax Identification Number (TIN): *
  Business Structure: *

  Proprietorship
  Partnership
  S Corporation
  C Corporation
  LLC
  
  Business Type: *

  Food/Restaurant
  Retail
  Service
  Day Care
  Other
  
  Brief Description of Business: *
  Do you Own or Rent the property where your business is located? *

  Own
  Rent
  
  Does your business operate out of a storefront or other non-residential space? *

  Storefront
  Non-residential space
  Other
  
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• # Employees, including owner (FTE): *
  DUNS: *
  SAM Registration: *

  Yes
  No
  
  Certified MBE/WBE: *

  Yes
  No
  
  Business has Liability Insurance: *

  Yes
  No
  
  Date Business was established & operating: *
  Is Business currently open: *

  Yes
  No
  
  Is Business currently disbarred from receiving federal money? *

  Yes
  No
  
  Business has business-related bank account? *

  Yes
  No
  
  Business owes Federal or State Taxes? *

  Yes
  No
  

  If yes, amount & type: *
  Business owes City of Meriden Taxes? *

  Yes
  No
  

  If yes, amount & type: *
  Owner or Business in Bankruptcy? *

  Yes
  No
  
  Annual Gross Business Revenue (2019): *
  Total Gross YTD: *
  Owner Hispanic or Latino? *

  Yes
  No
  
  Business Owner’s Race (Check All that apply): *

  White/Caucasian
  Black/African American
  Asian
  Native American/Alaska Native
  Native Hawaiian/Pacific
  Islander
  Other
  
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• Briefly describe how your business has been impacted by the public health emergency and associated business restrictions, including financial loss and whether any employees have been or will be laid off: *
  Amount of Funds Requested (up to $5,000): *
  Intended Use of Funds: *
  Will requested funds help Create or Retain jobs? *

  Yes
  No
  

  How Many: *
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• Have you received any assistance funds for COVID-19 Emergency Business Assistance?

  Yes

  No
  Source of Funding (1): *

  Insurance
  Small Business Administration (SBA) Loan
  Paycheck Protection Program
  Private or Non-Profit Sources
  Other
  

  Amount Awarded (1): *

  For What (1)? *

  Verification of Award (1): *

  Yes
  No
  

  Verification of Expenditure (1): *

  Yes
  No
  

  Amount Expended (1): *

  Remove Add

  Total Amount Awarded:

  Total Amount Expended:

  Total Duplication of Benefits:
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• Please note: If you are submitting a password-protected PDF, please be sure to submit the passwords in a separate document so the PDF can be opened and reviewed. All documents must be legible for the application to be considered.

  Por favor tome nota: si envía un PDF protegido con contraseña, asegúrese de enviar las contraseñas en un documento separado para que el PDF se pueda abrir y revisar. Todos los documentos deben ser legibles para que se considere la aplicación.

  Please note: maximum file upload size is 128MB

  Por favor tome nota: el tamaño máximo de carga de archivos es 128MB

  You may submit multiple files in the Tax Return and Evidence of Expenses sections.

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

  Select File - Front

  Select File - Back

  only jpg, png, pdf and office documents are accepted

  Please attach 2 consecutive years of full, signed tax returns with complete schedules, no older than 2017: *

  Select Files

  only jpg, png, pdf and office documents are accepted

  Please attach evidence of expenses to be paid: *

  Select Files

  only jpg, png, pdf and office documents are accepted

  Certifications

  By signing below, I make the following certifications:

  1. Any grant funds received will be used for business operating purposes as specified in the grant award; I understand that if the funds are used for unauthorized purposes, I shall return those grant funds and further may be subject to criminal fraud charges or civil action.
  2. I understand that, after successful submittal of the application, if I do not respond to requests for clarification, documentation, or information related to my application within 30 days, my application position will be forfeited and will only be reconsidered after all fully complete applications have been acted upon and if funding remains.
  3. I have not received funding from any federal, state, or any other COVID-19 related funding programs for the expenses I have requested funding for in this application. Any such “duplication of benefits” will result in the necessary return of the grant funds to the City of Meriden.
  4. Neither I nor any owner of my business is presently subject to an indictment or formal criminal charges, nor presently incarcerated.
  5. I understand that I will be required to execute a Grant Agreement outlining all of my responsibilities as an awardee, should my application be accepted and funded.
  6. I confirm that I, nor any one with whom I have families ties, has any functions or responsibilities with respect to HUD-funded activities, or is in a position to participate in the decision making process or gain inside information with regard to such activities.
  7. My business is current on all taxes due to the City of Meriden and no liens are on record against my business for unpaid taxes.
  8. I agree to cooperate with the City of Meriden in any audit or business review upon request and will retain records of expenses funded by this grant.
  9. I acknowledge and understand that Title 18 United States Code Section 1001: (1) makes it a violation of federal law for a person to knowingly and willfully (a) falsify, conceal, or cover up a material fact; (b) make any materially false, fictitious, or fraudulent statement or representation; OR (c) make or use any false writing or document knowing it contains a materially false, fictitious, or fraudulent statement or representation, to any branch of the United States Government; and (2) requires a fine, imprisonment for not more than five (5) years, or both, which may be ruled a felony, for any violation of such Section.

  Business Owner Signature *

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  Clear

  Date: 10/26/2020

    

  Business Co-Owner Signature

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  Clear

  Date: 10/26/2020

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