SMALL BUSINESS RELIEF

PROGRAM APPLICATION

Please complete all the requested information. TYPE your response in each box. An application completed by hand, if illegible, may be declined. Submission instructions are at the end of this application.

Applicant—Business Legal Name or Name of Sole Proprietor:

Cell Phone:

Business Name (if different from above):

Federal Tax ID / SSN (sole proprietor):

Business Street Address / City / State / Zip:

Business Phone:

Describe type of business and activities:

Date established: Email:

Years under current ownership:

Website:

Legal Entity: ☐ C-Corp ☐ S-Corp ☐ LLC ☐ Partnership ☐ Sole Proprietorship

☐ Non-Profit

Challenges caused by COVID-19:

☐ Payroll

☐ Vendors

☐ Rent/loan payments

☐ Business taxes/utilities

☐ Other

Do the Owners have ownership in any other business? If yes, list the affiliated business:

Employee Information: Report number of employees; part-time employees counted as a fraction of a full-time employee (FTE)

Will this grant allow you to retain employees? ☐ Yes ☐ No

Have you been approved for the SBA Paycheck Protection Program? ☐ Yes ☐ No If yes, what is the amount of your loan? __________

Number of employees on Feb 29, 2020 March 31, 2020: Expected new and/or re-hires (0-3 months): ___

Purpose of grant (Describe how the grant will help you continue operations or re-start your business following COVID-19):

Has the applicant been awarded any grant funds for COVID-19 relief? If so, which grant(s) have you been awarded?

Financial Information:

February 2020 March 2020 Projected April 2020

Monthly gross revenues

Monthly payroll expense

Monthly rent and utilities

Monthly loan payments (exclude RVCDF)

Outstanding vendor invoices

Cash in bank at end of month

OWNER INFORMATION

Name and Title

Date of Birth

Social Security Number

Address

Phone

% of Ownership

Attach a separate sheet for any additional owners. Total Ownership 100%

JPMC Small Bus Relief App Fill-in.docx

The following demographic information is used to monitor our compliance with various government and private grant organizations. You are not required to furnish this information but are encouraged to do so. RVCDF does not discriminate based

upon this information, nor on whether you choose to furnish it. However, if you choose not to furnish it, RVCDF may note your race and sex on the basis of visual observation or surname. This information will not be used in evaluating your application or to discriminate you in any way. Please check all that applies below:

☐ African American ☐ Latinx ☐ Native American ☐ Native Alaskan ☐ Asian ☐ Other Pacific Islander ☐ White ☐ Other

☐ Minority-owned business ☐ Woman-owned business ☐ Immigrant-owned business ☐ Veteran-owned business

If you are approved to receive this grant, you may be asked to participate in a survey after receiving funds.

APPLICANT’S STATEMENT

A. Applicant certifies:

1. The undersigned certifies that if Applicant is an entity other than a sole proprietorship, it is duly organized and validly existing under the law of the State of ______________ (if not filled in, Washington).

2. The undersigned certifies that their business —

a. Is located in southeast Seattle (east of I-5, south of I-90)

b. Is minority-owned (greater than 50% ownership)

c. Family income of business owner(s) falls within the limits for the Area Median Income (AMI) established by HUD (see table posted on web page)

d. Employs 10 or fewer full-time (or FTE) employees

e. Has a physical storefront (no home-based businesses)

f. Can demonstrate a loss of income due to COVID-19

B. Applicant authorizes:

1. RVCDF to obtain and review application provided by Applicant and to identify Applicant and its owners and officers as grant recipients in newsletters, annual reports and other publications produced by or for RVCDF.

2. RVCDF to compile portions of the Confidential Information with similar data of other applicants and to publish statistics derived from such compilations.

Each of the undersigned parties certifies that he or she is authorized to sign this application on behalf of Applicant.

X

Authorized Signature Print Name and Title Date

X

Authorized Signature Print Name and Title Date

APPLICANT SUBMISSION INSTRUCTIONS:

your entire tax return. E. Email your application and the first two pages of your most recent Federal tax return Form 1040 to: grants@rvcdf.org

APPLICATIONS WILL NOT BE ACCEPTED AFTER 9 PM ON MAY 8.

JPMC Small Bus Relief App Fill-in.docx

A. Type your responses in each box; handwritten applications may not be accepted if illegible. B. Save the application and name it with your business name and date (YYYYMMDD). Example: ABC Janitorial 2020-04-30. C. Each owner must sign and date the application. D. Scan pages 1 and 2 of your most recent (2018 or 2019, which has been filed with the IRS) tax return Form 1040. DO NOT send