RECOVERY GRANT APPLICATION ROUND 4

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DOCUMENTS NEEDED FOR APPLICATION:

  • 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
  • 941 Federal Payroll Tax Form (January-March 31, 2020)
  • Most recent 941 Payroll Tax Forms
  • Copies of all eligible receipts in excess of $12,500

  • INFORMATION AND DOCUMENTATION (*indicates required field)

  • OWNERSHIP INFORMATION

    Complete this section for each person who has 20% or more ownership interest in the business.
  • ADDITIONAL OWNERSHIP INFORMATION (If Applicable)

    Complete this section for each person who has 20% or more ownership interest in the business.
  • Drop files here or
  • APPLICANT QUALIFICATION QUESTIONNAIRE

    Program eligibility is limited to those businesses which meet the following qualifications.
  • Litigation Disclosure:

  • Notary is Required for the Affidavit!

  • 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.
    Drop files here or
  • Proposed Use of Grant Funds (Reimbursable Expenditures)

  • Drop files here or
  • ADDITIONAL INFORMATION REQUIRED

  • For quicker processing, please ensure that your uploaded documents are not password protected.

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  • 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:

  • 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:

  • If you are related to a City of Chesapeake employee:

  • If neither apply:

  • Acknowledgement

  • I HEREBY CERTIFY AND ACKNOWLEDGE THAT I HAVE READ THIS ENTIRE APPLICATION AS COMPLETED, AND THAT EACH RESPONSE IS TRUE, COMPLETE, AND ACCURATE.

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