Show Me Strong Personal Protective Equipment (PPE) Retooling

Program Checklist

Please include each of the following items as part of your application:

Completed Application Form

Certificate of Tax Clearance Along with the application, applicants must submit a Certificate of Tax Clearance from the Missouri

Department of Revenue or evidence that a submission was made prior to the application deadline toobtain the Certificate from the Missouri Department of Revenue.

MissouriBUYS Vendor Registration

E-Verify Memorandum

Retooling and Production Plan

PPE TIER DEFINITIONS:

TIER 1: ($500,000 maximum reimbursement) TIER 2: ($300,000 maximum reimbursement)

N95 Respirators Face Shields Medical Examination Gloves Gel Hand Sanitizer Disinfectant Wipes Surgical Masks Isolation Gowns Infrared Thermometers Temporal Testing Swabs Human Remains Pouches (HRPs)

Eye Protection/Goggles Other, as approved by DED Boot Covers

Medical Aprons Powered Air Purifying Respirator (PARP) Chemical and Biohazard Resistant Suits Procedure Masks Biohazard Bags

Other, as approved by DED

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Show Me Strong PPE Retooling Program

APPLICATION FORM

The Missouri Department of Economic Development (DED) is accepting applications for grant funding to manufacturers, nonprofit organizations, and other entities to reimburse certain costs for retooling existing facilities by purchasing necessary equipment and services to manufacture critically needed personal protective equipment (PPE) for use in Missouri. This grant funding will assist entities with creating new business while contributing to the fight against the current COVID-19 public health emergency. DED will review applications for eligibility of costs based on the Coronavirus Aid, Relief, and Economic Security (CARES) Act and related guidance from the U.S. Treasury. Under the CARES Act, the program is limited to reimbursing necessary expenditures made due to the current COVID-19 public health emergency and expended within the date range established by the program guidelines. The U.S. Treasury guidance on eligible costs is updated regularly; therefore, eligible costs are subject to change. DED reserves the right to make changes to, and final determination of, eligible program costs.

PART A: APPLICANT INFORMATION Office Use Only - ID #: _

Name of Applicant Business (incorporated name and d/b/a if applicable):

Missouri Business Charter Number (to retrieve, please visit: https://www.sos.mo.gov/BusinessEntity):

Missouri Tax I.D. Number: Federal Employer Identification Number:

Contact Person: Title:

Street Address 1: Alternate Address:

Street Address 2: Fax Number:

Phone Number: Mobile Number:

City: County: State: Zip Code:

Website: E-mail:

Year business was established in Missouri: How many employees did the business have in Missouri as of January 1, 2020?

How many employees does the business currently have in Missouri?

Describe the goods and/or services the business typically produces or provides:

Has the business been operating in Missouri for 3 years?

Yes No

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PART B: Funding Request

Grant funds may be used for retooling a facility, purchasing equipment, constructing facilities, complying with FDA requirements, building costs, design/engineering costs, technological upgrades for machinery, other costs as approved by the DED and as reasonably necessary to increase production of needed PPE. Grant funding is available for costs incurred after March 1, 2020.

Grant Amount Requested: Tier 1 PPE - $ ___________ (maximum grant $500,000) Tier 2 PPE - $ ___________ (maximum grant $300,000)

Use of Grant Funds:

Retooling existing facility

Acquisition of equipment necessary for increased production of PPE

Technological upgrades necessary to increase production of PPE

Other

Describe how the grant funds will be used to start/increase production of PPE:

How many full time employees will be created if this application is approved for funding? ___________

How many full time employees will be retained if this application is approved for funding? ___________

Has the company, its controlling shareholders/members, or any of its officers or directors filed for bankruptcy in the last 10 years?

Yes No

Does the company owe any fines, penalties, monies, or delinquent taxes to the U.S. government, any federal agency, the State of Missouri, any state agency, or any political subdivision of the state?

Yes No

In the past 10 years, has the company, any of its shareholders/members, or its officers or directors, been found liable by a court of competent jurisdiction for fraud, unfair or deceptive business practices, antitrust or securities law violations, corrupt practices, wrongful death, or infringement of intellectual property rights?

Yes No

Industry Type: Manufacturing Primary NAICS:________________ Secondary NAICS:_________________ Other NAICS:_________________________ Nonprofit Primary NAICS:________________ Secondary NAICS:_________________ Other NAICS:_________________________ Other Primary NAICS:________________ Secondary NAICS:_________________ Other NAICS:_________________________

Type of Ownership (check one): S Corporation C Corporation Limited Liability Corporation Limited Liability Partnership Partnership Cooperative Association Family-Owned Farm Other (please specify)

Ethnicity of majority owner: Asian Black or African American Hispanic or Latino American Indian /

Native Alaskan Native Hawaiian /

Other Pacific Islander White Two or more races Other

Sex of majority owner: Male Female

Veteran Owned Business? Yes No

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PART C: Production Plan

Project Start Date: _________________

Are you currently manufacturing PPE in Missouri? Yes No If so, what PPE are you producing?

Are you planning to convert an existing facility to produce PPE? Yes No

Will the PPE be produced at a Missouri facility? Yes No

If Yes, please provide the address:

Describe your plan to produce the PPE identified:

What challenges will the business face in expanding PPE production or converting to PPE manufacturing?

Does the business already have purchase orders to sell the PPE identified in the plan? Yes No

PPE to be produced Quantity to be produced per month Is FDA approval required? Has FDA approval been obtained? Please describe and date any steps undertaken to obtain

FDA approval

TIER 1YES

NO

N95 RespiratorsMedical Examination Gloves Disinfectant Wipes Isolation Gowns Testing Swabs Other, as approved by DED

TIER 2

Face Shields Gel Hand Sanitizer Surgical MasksInfrared Thermometers Temporal Human Remains Pouches (HRPs) Eye Protection/GogglesBoot CoversMedical ApronsPowered Air Purifying Respirator (PARP) Chemical/Biohazard Resistant Suits Procedure MasksBiohazard Bags

Minimum quantity: __________

Maximum quantity: __________

Minimum quantity: __________

Maximum quantity: __________

YES

NO

YES

NO

YES

NO

Other, as approvedby DED

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REIMBURSABLE EXPENSES

Retooling a facility Complying with FDA Requirements Consultant Costs Acquiring equipment Building Costs Technological Upgrades for Equipment Constructing facilities Design/Engineering Costs Other (as approved by DED)

Only reasonable costs for professional services will be accepted under the program with the reimbursement of such services at DED’s discretion.

PART D: MissouriBUYS

The business must register with the Missouri Office of Administration through MissouriBUYS. The vendor registration portal is available on the MissouriBUYS website at: https:// missouribuys.mo.gov.

PART E: E-VERIFY

• In addition to certifying that the organization does not employ illegal aliens, the organization must: 1) enroll in E- Verify, 2)confirm enrollment and participation in E-Verify on the Certification, and 3) provide supporting documentation;

• The E-Verify Program, conducted jointly by the U.S. Citizenship and Immigration Services (USCIS) Verification Division andthe Social Security Administration (SSA), is designed to provide employment status information to determine employmenteligibility;

• E-Verify requires that participating commercial employers use the automated Verification Information System (VIS) to checkthe SSA and the USCIS databases to verify the employment authorization of ALL newly hired employees;

• Employer participation in E-Verify is free. Access the E-Verify website at: https://e-verify.uscis.gov/enroll/.

PART F: CERTIFICATION OF STATEMENT

THE APPLICANT CERTIFIES THAT:

I, the undersigned, acting on behalf of the Applicant named below, hereby certify and agree to the following: • The information submitted by the Applicant to DED in connection with this application is true and correct and such

information is consistent with documents provided other government programs. The Applicant hereby authorizes DED toverify such information from any source;

• The Applicant, contact person(s), owners, or signatories identified in the application (Please mark appropriate box. If youmark “Have” or “Are”, please provide an explanation):a) Have Have not--committed a felony, is currently under indictment for a felony, or is currently on parole or

probation; Explanation: _______________________________________________________________________________________

b) Are Are not--delinquent with respect to any non-protested federal, state or local taxes or fees;Explanation: _______________________________________________________________________________________c) Have Have not--filed (or is about to file) for bankruptcy, unless otherwise disclosed to DED; orExplanation: _______________________________________________________________________________________d) Have Have not--failed to fulfill any material obligation under any other state or federal program;Explanation: _______________________________________________________________________________________

There are no pending or threatened liens, judgments, or material litigation against the Applicant or any person identified onthe application which is likely to have a material impact on the Applicant’s viability;

I certify that the Applicant does NOT knowingly employ any person who is an unauthorized alien and that the Applicant hascomplied with federal law (8 U.S.C. § 1324a) requiring the examination of an appropriate document or documents to verifythat each individual is not an unauthorized alien.

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• I certify that the Applicant is enrolled and will participate in a federal work authorization program as defined in Section285.525(6), RSMo, with respect to employees working in connection with the activities that qualify Applicant for thisprogram. I certify that the Applicant will maintain and, upon request, provide DED documentation-demonstratingApplicant’s participation in a federal work authorization program with respect to employees working in connection with theactivities that qualify Applicant for this program.

• I certify that the Applicant shall include in any contract it enters with a subcontractor in connection with the activities thatqualify Applicant for this program, an affirmative statement from the subcontractor that such subcontractor is not knowinglyin violation of Section 285.530.1, RSMo, and shall not be in violation during the length of the contract. In addition, theApplicant will receive a sworn affidavit from the subcontractor under the penalty of perjury, attesting that thesubcontractor’s employees are lawfully present in the United States. I certify that the Applicant will maintain and provideDED and the Missouri Office of Administration access to documentation demonstrating compliance with this requirement.

• I understand that, pursuant to Section 285.530.5, RSMo, a general contractor or subcontractor of any tier shall not be liable underSections 285.525 to 285.550, RSMo, when such general contractor or subcontractor contracts with its directsubcontractor who violates Section 285.530.1, RSMo, if the contract binding the contractor and subcontractor affirmatively statesthat the direct subcontractor is not knowingly in violation of Section 285.530.1 and shall not subsequently be in such violation andthe contractor or subcontractor receives a sworn affidavit under the penalty of perjury attesting to the factthat the direct subcontractor’s employees are lawfully present in the United States.

• I understand that if the Applicant is found to have employed an unauthorized alien, Applicant maybe subject to penalties pursuantto Sections 135.815, 285.025, and 285.535, RSMo.

• I understand that if the Applicant is found to have employed an unauthorized alien in Missouri and did not, for thatemployee, examine the document(s) required by federal law, the Applicant shall be ineligible for any state-administered orsubsidized tax credit, tax abatement or loan for a period of five years following any such finding.

• I attest that I have read and understand the Show Me Strong PPE Retooling Program guidelines.• I hereby authorize DED to share the Applicant’s information as DED deems necessary to process the application and

administer the grant.• I hereby agree to allow representatives of DED and its designees access to the project property and records as may be necessary

for the administration of any grant issued to Applicant for this program.• I certify under penalties of perjury that the statements and information contained in the application and attachments are complete,

true, and correct to the best of my knowledge and belief.

Applicant Signature Print Name Title Date

SUBMIT APPLICATION

I certify I have the proper authority to execute this document on behalf of the Applicant and that I am authorized to make the statement of affirmation contained herein. I also realize that failure to disclose material information regarding the Applicant, any owners or individuals engaged in themanagement of the Applicant, or other facts may result in federal or state criminal prosecution and civil liability.

Signature instructions:To digitally sign this application, please use the "Fill & Sign" function in Adobe Reader or Adobe Acrobat.Click the Sign icon in the toolbar. Then type your name, draw your signature, or select an image of your signature.Place the text or image in the signature box above.

Please note: For the purposes of this application, a digital signature is the equivalent of a written signature.

I acknowledge that this signature serves as an equivalent to a normal written signature.