Recovery Grant Application Round 3

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BEFORE STARTING THE APPLICATION, PLEASE ENSURE THAT YOU HAVE THE FOLLOWING:

Required Affidavit form (Signed by public notary)
Required W-9 form
2019, 2020, and current YTD financial statements (P/L and balance sheets)
DD-214 (To verify veteran status, if applicable)
Ownership documentation (If needed)
Reimbursable receipts
Federal Payroll Tax Form (January-March 31, 2020)
941 Payroll forms for the quarters ending March and June 2020
Copies of all eligible receipts in excess of $10,000

Application ID:
INFORMATION AND DOCUMENTATION (* indicates required field)
Business Legal Name:*
DBA or Tradename (if applicable):*
Business Information:*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Phone:*
Cell Phone:*
Email:*
Website:
When did the business start operating / open in Chesapeake?*
MM
DD
YYYY
Federal Tax ID# (EIN):*
Chesapeake Business License #:*
Legal structure (choose one):*
- Sole Proprietorship
- LLC
- Corporation
- Partnership
- Independent Contractor
Check all that apply:
- Small, Women, and Minority Owned (SWaM) Certified
- Small, Women, and Minority Owned (SWaM) Eligible
- Veteran-Owned (must provide copy of DD-214)
If Veteran-owned, please provide a copy of DD-214:
As of February 29, 2020, do you have employees?*
- Yes
- No
If yes, how many?
Description of business:*
OWNERSHIP INFORMATION
Complete this section for each person who has 20% or more ownership interest in the business.
Name:
First Last
Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone:
Work Phone:
Mobile Phone:
Email:
Position:
Percentage of ownership:
ADDITIONAL OWNERSHIP INFORMATION (If Applicable)
Complete this section for each person who has 20% or more ownership interest in the business.
Name:
First Last
Home Address:
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Home Phone:
Work Phone:
Mobile Phone:
Email:
Position:
Percentage of ownership:
If you have additional ownership information, please upload additional documents here:
Drop files here or
APPLICANT QUALIFICATION QUESTIONNAIRE
Program eligibility is limited to those businesses which meet the following qualifications.
Has the business been established and operational in the City of Chesapeake for at least the past 12 months (since March 1, 2019)?
- Yes
- No
Is the business current on all City of Chesapeake tax obligations?
- Yes
- No
Litigation Disclosure:
A. Have you, or any principal, officer, or director of your company been involved in any claim or litigation with the City of Chesapeake during the last ten (10) years?
- Yes
- No
B. Has any parent company or wholly owned subsidiary of your company been involved in any claim or litigation with the City of Chesapeake during the last ten (10) years?
- Yes
- No
If you answered “yes” to A and/or B above, please state the name(s) of the person(s), the nature and the status, and/or outcome of the litigation:
How often do you process and run payroll?
- Weekly (52x per year)
- Bi-weekly (26x per year)
- Semi-monthly (24x per year)
- Monthly (12x per year)
Total number of employees as of February 29, 2020:
Full Time:
Part Time:
Total number of employees as of last payroll run:
Full Time:
Part Time:
Total number of employees either laid-off or furloughed as a result of COVID-19 (since February 29, 2020):
Full Time:
Part Time:
Describe how business operations have been adversely impacted by the COVID-19 pandemic. Describe your plans for current and near term operations (during reduced COVID19 business restrictions) in order to remain operational. Identify how you have maintained employment of all or certain employees and the type of positions being retained in comparison to preCOVID-19 disruption:
Please list all grant/loans and dollar amounts received from SBA programs via the 2020 CARES Act:
Notary is Required for the Affidavit!
Please Upload Your Notarized Affidavit Here:*
This affidavit certifies that all expenses for which grant proceeds are sought are related to COVID-19 related expenses, and that these expenditures have not been submitted as part of a successful grant application under the Payroll Protection Program (“PPP”) or the CARES Act.
Proposed Use of Grant Funds (Reimbursable Expenditures)
Building Rent/Mortgage Payments Amount ($)
Description:
Working Capital Amount ($):
Description:
Inventory Amount ($):
Description:
Supplies Amount ($):
Description:
Marketing/Advertising ($):
Description:
Amount Total ($):
Upload Receipts for Reimbursable Expenditures:*
Drop files here or
ADDITIONAL INFORMATION REQUIRED
For quicker processing, please ensure that your uploaded documents are not password protected.
The most recent year-end 2019 and 2020 financial statement (P/L Statement & Balance Sheet)*
Drop files here or
Current Year-to-date financial statement (P&L Statement & Balance Sheet)*
Drop files here or
Federal Payroll Tax forms for January – March 31, 2020.*
Drop files here or
Most recent Federal Payroll Tax forms.*
Drop files here or
W-9 Form*
In order to receive grant monies, a completed W-9 is required and should be uploaded here. If you do not have a completed W-9, you can download a blank form at the top of this application to complete.
Drop files here or
By checking the below each applicant agrees to the following statements:
*
I acknowledge that this completed and signed application is only an application for the disaster assistance grant funds expressed herein. This application, even if favorably received, does not constitute a commitment on the part of the EDA to extend grant funds.*
*
I agree to notify the EDA immediately in writing if any of the information contained in this application materially changes in any respect.*
*
I agree to hold harmless and indemnify the EDA and its board members, employees, agents, representatives and associates against any claims, charge, suit, damages or other similar liability and to further waive any claims against the EDA whether now existing or arising in the future regarding any damages, losses, liability, costs or expenses (including any attorney fees) incurred and arising from this application.*
*
I understand that by submitting this application the EDA is under no obligation to approve and/or extend an assistance grant.*
Non-Discrimination in Grant Awards
The EDA does not discriminate against faith based organizations in accordance with Code of Virginia Section 2.2-4343.1 or against any grant applicant because of race, religion, color, sex, national origin, age, disability or any other basis prohibited by state law.
PLEASE CHECK AND COMPLETE APPROPRIATE BOX
Only complete sections that apply to you.
If you are a City of Chesapeake employee:
I am a City of Chesapeake employee
- I am a City of Chesapeake employee
I work for City of Chesapeake in the Department of:
If you are related to a City of Chesapeake employee:
I am related
- I am related to a City of Chesapeake employee
Their name is:
They work for:
- City of Chesapeake Department (please list department below)
- Chesapeake EDA Board Member
- Any Chesapeake elected or appointed official
City of Chesapeake Department of:
My relationship to the person above:
- Spouse
- Father
- Mother
- Daughter
- Son
If neither apply:
Neither Apply
- I am not related to an employee of the City of Chesapeake, Chesapeake EDA, nor am I an employee of the City of Chesapeake.
Acknowledgement
I HEREBY CERTIFY AND ACKNOWLEDGE THAT I HAVE READ THIS ENTIRE APPLICATION AS COMPLETED, AND THAT EACH RESPONSE IS TRUE, COMPLETE, AND ACCURATE.
Signature*
Title:
Date:*
MM
DD
YYYY

Save and Continue Later

Recovery Grant Application Round 3

Required Affidavit form (Signed by public notary)

Required W-9 form

2019, 2020, and current YTD financial statements (P/L and balance sheets)

DD-214 (To verify veteran status, if applicable)

Ownership documentation (If needed)

Reimbursable receipts

Federal Payroll Tax Form (January-March 31, 2020)

941 Payroll forms for the quarters ending March and June 2020

Copies of all eligible receipts in excess of $10,000

INFORMATION AND DOCUMENTATION (* indicates required field)

OWNERSHIP INFORMATION

ADDITIONAL OWNERSHIP INFORMATION (If Applicable)

APPLICANT QUALIFICATION QUESTIONNAIRE

ADDITIONAL INFORMATION REQUIRED

PLEASE CHECK AND COMPLETE APPROPRIATE BOX

Acknowledgement

Why Chesapeake

Business Services

Living Here

Data & Reports

Business Resources

Media Center

Chesapeake Small Business COVID-19 Recovery Grant Application

Recovery Grant Application Round 3

Required Affidavit form (Signed by public notary)

Required W-9 form

2019, 2020, and current YTD financial statements (P/L and balance sheets)

DD-214 (To verify veteran status, if applicable)

Ownership documentation (If needed)

Reimbursable receipts

Federal Payroll Tax Form (January-March 31, 2020)

941 Payroll forms for the quarters ending March and June 2020

Copies of all eligible receipts in excess of $10,000

INFORMATION AND DOCUMENTATION (* indicates required field)

OWNERSHIP INFORMATION

ADDITIONAL OWNERSHIP INFORMATION (If Applicable)

APPLICANT QUALIFICATION QUESTIONNAIRE

ADDITIONAL INFORMATION REQUIRED

PLEASE CHECK AND COMPLETE APPROPRIATE BOX

Acknowledgement

Why Chesapeake

Business Services

Living Here

Data & Reports

Business Resources

Media Center