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COVID-19 Grant Application Form

A detailed application letting business owners request pandemic relief funding by reporting revenue, staffing, expenses, and how the funds will be used.

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Name of Business

Business Phone Number

Business Email

Business Address

Dirección

Ciudad

Estado / Provincia

Código postal

Primary Contact Person

Nombre

Apellido

Phone Number of Primary Contact Person

Business License Number

Is this a lease property?

Yes No

Is this residential or commercial?

Residential Commercial

Year of Establishment

Number of Employees

Payroll Type

W-9 IRS Form

Max 10 MB per file

Invoices and receipts for reimbursement

Max 10 MB per file

Certificate of Good Standing

Max 10 MB per file

Copy of State Business Licenses

Max 10 MB per file

Does the business have outstanding liens or pending legal issues caused by the pandemic?

Yes No

How is the business currently funded?

Does the owner have any pending legal issues?

Yes No

Was your business affected by the pandemic?

Yes No

Did the pandemic cause problems with daily business operations?

Yes No

Please describe the business issues you encountered during the pandemic

Was the number of your employees affected because of the pandemic?

Yes No

Were you able to hire new employees during this pandemic?

Yes No

Were there any lay-offs?

Yes No

Did you already apply for financial support from another institution or the government?

Yes No

If yes, please indicate the institution

Application status

Pending Approved Rejected

Please describe the revenue and loss of your business during this pandemic

Additionally, upload a summary of costs document (reopening costs, rent, etc.)

Max 10 MB per file

Where will you use the funding if granted?

When does your business need the fund?

I certify that the information provided is true and correct

Signature

Sign here

Date Signed

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