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Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 1 The purpose of this grant program is to assist small businesses in Elbert County, Colorado that have been adversely affected by COVID-19. Grants are available to assist with payroll, capital, equipment, and operating costs incurred due to the COVID-19 economic disruption. Grant funds under this program do not need to be repaid. Which businesses qualify? 1. The business is physically located in Elbert County, Colorado and is not a franchise or part of a chain of more than three locations. 2. The business has been operating since March 16, 2019. 3. The business is a for-profit business with at least 1 (including a sole proprietor), but not more than 50 employees. 4. The business is registered with the Colorado Secretary of State and is in good standing. 5. The business’ gross annual revenues in 2019 did not exceed $5 million. 6. The business has been forced to shut down or forced to operate at limited capacity due to COVID-19 or Public Health Orders related to COVID-19 resulting in a loss in revenue. Note: the business must be able to provide documentation supporting this loss in revenue. 7. The business continues to operate legally during the COVID-19 crisis. 8. Individuals that own or have interest in more than one business are limited to one grant if a person has ownership interest in three businesses, only one of those businesses may receive a grant under this program). 9. You must accurately disclose whether you are (or are not) an employee of Elbert County Government, an Elected Official in Elbert County Government, or a member of an employee’s or Elected Official’s immediate family. How much is the grant? A total of up to $750,000 is available for the grant program as of October 19, 2020. Grants are expected to be awarded in amounts up to $10,000; exceptions to that amount may be authorized on a case-by-case basis. How do I apply? Complete the Grant Application and Participation Certification, which can be found online at www.elbertcounty-co.gov. Return the completed application and all the required information on the Document Checklist via email to [EMAIL REDACTED]. You will receive an email advising you that your application has been received. An incomplete application will delay the review of your application. Listed documentation is a minimum requirement and staff may request additional documentation to determine eligibility. If you have any questions, please email the County’s Public Information Officer at [EMAIL REDACTED], or leave a message at (720) 639-5850. Funding is limited and will be disbursed on a first come, first served basis. Applications for Round 2 are due by November 9, 2020; this deadline may be extended depending on demand. ---PAGE BREAK--- Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 2 BUSINESS INFORMATION Name of Business: Type of Business LLC, corporation, sole proprietorship): Address of Business: Business Employer Identification Number (EIN): Years in Business: # of Employees (as of date of application): OWNER INFORMATION OWNER Name: Contact Phone (area code): Current Residential Address (street, city, state, zip): Email Address: CO-OWNER Name: Contact Phone (area code): Current Residential Address (street, city, state, zip): Email Address: ---PAGE BREAK--- Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 3 BUSINESS INCOME INFORMATION 2019 INCOME: Month #1 Gross Sales: $ (Month of ) Month #2 Gross Sales: $ (Month of ) 2020 INCOME (USE THE SAME MONTHS AS 2019) Month #1 Gross Sales: $ (Month of ) Month #2 Gross Sales: $ (Month of ) Please provide a brief explanation of the adverse economic effects COVID-19 has had on your business: REQUIRED DOCUMENTS-SEE DOCUMENT CHECKLIST FOR DOCUMENTS ACCEPTED FOR VERIFICATION 1. A copy of the business’ most recent tax return including IRS Form 941, if applicable. 2. A completed IRS Form W-9 3. A budget that demonstrates grant funds will be used to address business needs caused by business interruption between March 1, 2020 and the date of the application. 4. Revenue statements for 2 months in 2020 verifying loss of revenue compared to the same months in 2019. 5. Revenue statements for the same two months in 2019. 6. Annual revenue statement for 2019. 7. Payroll reports documenting the number of employees. ---PAGE BREAK--- Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 4 ACKNOWLEDGMENT AND CERTIFICATION Acknowledgement: I/We understand that this grant is being provided by Elbert County, Colorado based solely upon the information that I/we have provided in this application. I/We also certify that there are no outstanding tax liens or legal judgements against the business. Certification: I/We certify that the information provided in this application is true and complete to the best of my/our knowledge as of the date set forth opposite my/our signature(s) in this application and acknowledge my/our understanding that any intentional or negligent misrepresentation(s) of the information contained in this application may result in civil liability and/or criminal penalties. By signing below, I/we certify that the above statements are true and correct to the best of my/our knowledge. I/We understand that a false statement may disqualify me/us from benefits. Owner Signature: Date: Co-Owner Signature: Date: ---PAGE BREAK--- Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 5 Business Name: Business Address: In order to participate in the Elbert County Small Business Assistance Program ("Program") and receive a grant, Elbert County ("County") requires that you ("Recipient") and your staff, if applicable, certify the following: • You own a small business that employs between 1 and 50 employees. • Your business is legally operating during the COVID-19 crisis. • Your business has been in operation in Elbert County, Colorado for at least one year. • Your business is not a franchise and is not a chain of three or more locations • You have accurately disclosed whether you are (or are not) an employee of Elbert County Government, an Elected Official in Elbert County Government, or a member of an employee’s or Elected Official’s immediate family. • You commit to continue operating for a minimum of two months after receipt of the grant funds. Notwithstanding any other rights of the County under other Sections of this Certification or applicable law, if the Recipient violates any of the terms, covenants or provisions of the Certification, or if any representation or warranty made by the Recipient in this Certification or in any document or application submitted in connection with this Certification or the Program shall prove false or misleading, or if, in the sole judgment of the County, the conduct of the Recipient is such that the interests of the County have been or are likely to be impaired or prejudiced, the County shall thereupon have the right to terminate any grant to withhold payments due under the Program and/or demand and obtain the return of payments already made which are equal to the damages the County may have already suffered due to a breach by the Recipient. Any such action by the County shall not give rise to any cause of action for damages against the County. I certify that my business has been in operation for at least one year. I certify that I currently employ a total of employees. I certify that as a result of COVID-19, my business experienced a decrease in revenue for two consecutive months after January 1, 2020, compared to the average revenue for the same two-month period in calendar year 2019 (or average revenue based on total 2019 sales). I certify that my business is continuing to operate during the COVID-19 crisis. I certify that my business will continue to operate for a two-month period commencing on the date of receiving the grant funds. I certify that my business will comply with all program requirements, including state and federal laws. ---PAGE BREAK--- Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 6 I certify that I have not misrepresented the eligibility of my business for the Program. I certify that my business is complying with and will continue to comply with applicable state and local public health orders relating to COVID-19. I certify that either my business did not receive funds from the Paycheck Protection Act, and/or that any funds awarded under the Elbert County COVID- 19 Business Relief Grant program will be utilized for purposes other than the purposes for which the business used Paycheck Protection Act funds. By signing below, I certify that the above statements are true and correct to the best of my knowledge and belief. I understand that the willful or fraudulent submission of a materially false statement in connection with the certification may disqualify my business from eligibility for the Program benefits and may subject my business or myself to criminal charges. This certification shall be deemed executed in the County of Elbert and the State of Colorado and shall be governed and construed in accordance with the laws of the state of Colorado and the laws of the United States. (Business Owner Signature) (Date) (Business Owner Signature) (Date) ---PAGE BREAK--- Elbert County, Colorado 2020 COVID-19 BUSINESS RELIEF PROGRAM GRANT APPLICATION – Round 2 Elbert County, Colorado 2020 COVID-19 Business Relief Program Grant Application Round 2 (10/07/2020) 7 Document Why we need this Documents accepted Signed participation certification Verification that the business employs between 1 (including a sole proprietor) and 50 employees and has experienced a loss of revenue. Completed certification form. Revenue statements for two consecutive months in 2020. Documentation of revenue following COVID-19 impact. One or more of the following for the entire impacted period: point-of-sale reports, sales reports (demonstrating fees collected or earned income), bank statements, quarterly sales tax filings, or CPA-reviewed profit & loss statements for two consecutive months in 2020. Revenue statements for the same two consecutive months in 2019. Comparison of typical operating revenue to verify loss of revenue as a result of COVID-19. One or more of the following for the same two months in 2019: point- of- sales reports, sales reports (demonstrating fees collected or earned income), bank statements, quarterly sales tax filings, or CPA-reviewed profit & loss statements for two consecutive months in 2019. Annual revenue statements for 2019. Comparison of typical operating revenue to verify loss of revenue as a result of COVID-19. One or more of the following for total 2019 sales: point-of-sales reports, sales reports (demonstrating fees collected or earned income), bank statements, quarterly sales tax filings, 2019 tax returns (all pages), CPA- reviewed profit & loss statements, or Federal 990. Payroll report showing number of employees. To determine eligibility for the grant. Payroll records Proof of Elbert County location. To verify that the business is located in Elbert County, Colorado. Signed federal tax forms, signed copy of lease agreement, or 3 months of operational bills.