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  • Meriden Small Business COVID-19 Emergency Relief Grant Program
    Application

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


      Do you have sufficient documentation of expenses in PDF format to support the amount of funding being requested? *


      Do you know your business’s annual gross revenue for 2019 and the YTD gross revenue for 2020? *


      Do you have a DUNS number? *


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


      Secondary Owner's Household Income: *
      Number of people in Secondary Owner's household: *
    • Applicant/Owner Name: *
      Owner Social Security Number (SSN): *
      Owner E-Mail: *
      Owner Address - Street Address: *
      Owner Address - City: *
      Owner Address - State: *
      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: *
      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: *
      Business Physical Address - ZIP Code: *
      Is mailing address the same as physical address? *


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





      Business Type: *





      Brief Description of Business: *
      Do you Own or Rent the property where your business is located? *


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



    • # Employees, including owner (FTE): *
      DUNS: *
      SAM Registration: *


      Certified MBE/WBE: *


      Business has Liability Insurance: *


      Date Business was established & operating: *
      Is Business currently open: *


      Is Business currently disbarred from receiving federal money? *


      Business has business-related bank account? *


      Business owes Federal or State Taxes? *


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


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


      Annual Gross Business Revenue (2019): *
      Total Gross YTD: *
      Owner Hispanic or Latino? *


      Business Owner’s Race (Check All that apply): *
    • 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? *


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

      Source of Funding (1): *





      Amount Awarded (1): *
      For What (1)? *
      Verification of Award (1): *


      Verification of Expenditure (1): *


      Amount Expended (1): *
      Total Amount Awarded:
      Total Amount Expended:
      Total Duplication of Benefits:
    • 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: *

      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: *

      only jpg, png, pdf and office documents are accepted

      Please attach evidence of expenses to be paid: *

      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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      Date: 10/26/2020

        

      Business Co-Owner Signature

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      Date: 10/26/2020

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