FLORENCE F IRST A LOCAL BUSINESS COVID-19 RELIEF GRANT

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BUSINESS INFORMATION

1. Business Name:

2. Doing Business As (DBA):

3. Business Type: ☐ LLC ☐ Partnership ☐ Sole Proprietor ☐ Other

4. Business Street Address:

5. City: Florence 6. Zip Code: 7. Business Phone:

8. Business Mailing Address:

9. City: 10. Zip Code:

11. Person Completing Application: 12. Title:

13. Owner Name:

14. Owner Home Street Address:

15. City: 16. Zip Code: 17. Owner Phone:

18. Email: 19. 2nd Email, optional:

20. DUNS No:[For DUNS Retrieval or Apply for New - www.dnb.com/duns-number.html]

21. Incorporation Date:

22. Has the business ever been subjected to criminal or civil fines and penalties including from City Florence codeor regulatory violations or in bankruptcy? Is the business or business owner delinquent in any city, federal,

state taxes, child support? ☐ Yes ☐ No

EMPLOYEE INFORMATION

23. Number of Full Time Employees (FTE): 24. FT Hours ☐29+ ☐35+ ☐40+

25. Number of Part Time Employees (PTE):

26. Number of employees laid-off, furloughed, etc. FTE PTE

27. Number of employees retained or reinstated if grant is awarded: FTE PTE

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28. BUSINESS DESCRIPTION: Summary of owner’s experience in industry. Consider education, length ofownership, other related work or ownership experience. This information may be in a bulleted list ornarrative.

29. BUDGET

Amount of Request Fixed Cost Item Applicant Notes

Payroll expenses

Rent/mortgage

Utilities

Inventory

Other(specify):

Total Request

EMERGENCY NEED

30. Briefly describe the impact the COVID-19 pandemic has had on your business.

31. How will this funding assistance help your business remain viable and prevent job loss?

32. If applicable, describe innovations in your business created to meet or mitigate the changing demand duringthe COVID-19 pandemic. (e.g. new jobs, new management practices, professional development, collaborations, product or

service pivoting)

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I hereby certify that the information on this form is complete and accurate. I understand that the information provided may be subject to further verification by the City of Florence. If necessary, I will provide the information required to verify this data (e.g. payroll records, tax fillings, bank account statements, etc.).

I, therefore, authorize such verification, and I will provide the supporting documentation, if necessary.

36. Date

37. Owner Name

38. Owner Signature

39. Applicant Name and Title

40. Applicant Signature

OTHER FUNDING

33. Describe other funds you have or intend to apply for including sources of those funds and total amount (e.g.

SBA loan, unemployment insurance benefits, etc.)

34. Describe any other gaps in financing you might have to prevent employee layoffs or create new jobs and your

plan to fill those gaps.

35. Will you or are you receiving any “Business Interruption Insurance” ☐ Yes ☐ No

SUPPORTING DOCUMENTATION CHECKLIST

41. Florence First Grant Application

42. Owner Income(s) self-verification form using template in Appendix A

43. Owner letter self-verifying filing status of business income taxes for tax years 2017, 2018, and 2019

44. 2 most recent months of invoices documenting all items requested in Budget section.

45. Copy of liability insurance

46. Previous four weeks of payroll or other documents showing a history of employees on payroll as of theapplication submission date

DISCLOSURES

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Business Owner Income Documentation and Conflict of Interest Certification

o Items 47 and 48: Income is defined as the annual gross income (before deductions) of all family and non-familymembers 18+ years old living in the household. All sources of income must be counted from all persons in the householdbased on the anticipated income expected in the next 12 months.

o Items 49 and 50: Demographic information is collected for reporting purposes.

47. Total Persons in Business Owner Household 48. Business Owner Annual Household Income

☐ 1 ☐ $43,050 or less ☐ Above $43,050

☐ 2 ☐ $49,200 or less ☐ Above $49,200

☐ 3 ☐ $55,350 or less ☐ Above $55,350

☐ 4 ☐ $61,450 or less ☐ Above $61,450

☐ 5 ☐ $66,400 or less ☐ Above $66,400

☐ 6 ☐ $71,300 or less ☐ Above $71,300

☐ 7 ☐ $76,200 or less ☐ Above $76,200

49. Owner Ethnicity ☐ Hispanic/Latino ☐ Non-Hispanic/Latino

50. Owner Race: White Black or African American Asian

Native Hawaii/Other Pacific Islander Other or Multi-Racial

CONFLICTS OF INTEREST

I hereby declare that any person(s) employed by the City of Florence, who has direct or indirect personal or financial interest in this application or in any portion of the profits that may be derived there from, has been identified and the interest disclosed below. [Please include in your disclosure any interest which you know of. An example of a direct interest would be a City of Florence employee or elected official who would be paid to perform services under this proposal. An example of indirect interest would be a City of Florence employee who is related to any officers, employees, principal or shareholders of your firm or to you. If in doubt as to status or interest, please disclose to the extent known].

I hereby certify that the information on this form is complete and accurate. If necessary, I will provide the information required to verify this data (e.g. pay stubs, bank account statements, etc.). I, therefore, authorize such verification, and I will provide the supporting documentation, if necessary.

51. Date

52. Owner Name

53. Owner Signature

54. Disclosed Conflicts

APPENDIX A

Completed Application plus all Supporting Documentation must be submitted via e-mail to:cdbg@florenceal.org

Application Submittal Period Opens Friday May 8, 2020 at 6:00 amApplication Submittal Period Closes Thursday May 14, 2020 at 5:00 pm

Late or Incomplete Submissions will be disqualified.