Small Business Fund Application Form

Small Business Fund Application Form
Applicant Information
Name of Applicant
PrefixFirst NameMiddle NameLast Name
Applying as
How many full time employees do you have?
Business Information
Business Name
Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
What county is your business located in?
Additional business address location(s):
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
E-mail of Applicant
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Business Assessment and Forecast Plan
Please provide a brief overview of the small business. Include a summary about the business including information about products and/or services, operation hours and days, and the target markets it serves.
Please describe the impact that COVID-19 has caused.
Is the business currently operating?
If no, what date did business close?
MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
If yes, Please provide a brief description of the plan to operate during the next six months.
If no, Please provide a brief description of the plan to reopen within the next six months.
Will you reopen in the same county your business is/was in?

Insurance and Financial Section
Do you have insurance that will help to cover your short-term losses from COVID-19 (coronavirus)? If yes, please complete table with the appropriate options.

Insurance and Financial Information Table 1

Rows	Coverage	Deductible Amount $	Claim Submitted	Funds Received	Amount Received $
*Property Insurance
Commercial General Liability Insurance
Directors/Officers Insurance
Errors & Omissions Coverage
Workers Compensation Insurance
Other

*Standard property insurance policies usually include two types of valuable coverage for disruptions like the coronavirus. Business interruption coverage insures against losses resulting when the policyholder’s operations are directly affected; and contingent business interruption coverage insures against the risk of indirect losses, such as when suppliers or customers are affected.

Insurance and Financial Information Table 2. These are Payment Deferments that are in process or completed.

Rows	Response	12/19 or 1/20	COVID-19 Impacted Cash Flow (1 month)
Rent Deferred for Business Lease
Accounts Payable Renegotiated/Extended
Deferred Business Installment Debt
Deferred Business Credit Card Debt
Any "other" Business Deferments

Disaster Relief Budget Worksheet
Calculator
Please provide January-March Budget for Household
Rows 12/19 or 1/20 COVID-19 Impacted Cash Flow (1 Month)
Household Income
Household Expenses
Balance
Please provide January-March Budget for Business
Rows 12/19 or 1/20 COVID-19 ImpactedCash Flow(1 Month)
Business Revenue
Business Expenses
Balance
Cash Flow needed for 6 months (Balance is multiplied x -6)
Sources to cover 6 month cash flow gap.

Expenses Modified or In Process of Modification

Rows	Monthly Budget Projected
Total Rent Deferred
Accounts Payable Extended
Business Debt Payments Deferred
Available Credit in Lines Open
Insurance Benefits Expected
Any Other Deferred Expenses
Business Cash Available
Personal Savings
Other
Total Available
Working Capital GAP/Request

Working Capital Gap/Request is the Cash flow needed for six months take away from all modified expenses.
Calculator

Grant Amount Requested and Documentation
Grant Amount Requesting
How will you use the Grant Funds
Other
Please include receipts and documentation of the costs that the grant will cover. For the documentation please include the following 1. Documentation of transactions over the last 90 days 2. Bank Statements for at least the last three months.
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Applicant Information