Applicant/Business Owner

Name of Applicant

Street

City

State

Zip Code

Phone Number

Email Address

Business

Name of the Business

Legal Entity Name

Business Employer Identification Number (EIN)

Street

City

State

Zip Code

Year Business Started

Website

Type of Business

What is your for-profit business structure? (Non-profits are ineligible).
—Please choose an option—Sole ProprietorPartnershipLimited Liability CompanyS-CorporationC-Corporation

Total Grant Amount Requested (Up to $10,000):

Do you have a current business license with the City of Buena Park for a minimum of six months?
YesNo

How has your business been impacted by COVID-19 (Mark all that apply):
The business has been deemed non-essential and has been forced to shut down by the state or local government;Sales from the business are down more than 25% compared to the previous three months (Prior to February 15, 2020);The business has had to lay off at least one of its employees (full- or part-time employee);One or more of the employees in the business have contracted COVID-19 while at work;

Community Development Block Grant (CDBG) Eligibility

The business applicant must meet the CDBG eligibility requirement:
The business owner’s current household income is at or below 80% of the Orange County median income, adjusted for household size; OR
The business intends to retain at least one full-time equivalent, permanent low- and moderate-income job and the business owner(s):
Can show that 51% of its employees are low- and moderate-income, full-time or equivalent employees; and
Agrees that the grant funds provided will ensure permanent employment of the retained employee for a period of two years; and
Agree that if the low- and moderate-income job retained under this program is vacated within two years of the date of assistance, the business will take the necessary steps to fill the position with another low- and moderate-income employee for two years following the date of assistance.

Please review the chart above and mark the options below that apply:
My household income as the business owner is at or below 80% of the Orange County median income adjusted for household sizeI (or the business) intends to retain at least one full-time equivalent, permanent low- and moderate-income job and the business owner(s):Can show that 51% of its employees are low- and moderate-income, full-time or equivalent employees; and Agrees that the grant funds provided will ensure permanent employment of the retained employee for a period of two years; and Agee that if the low- and moderate-income job retained under this program is vacated within two years of the date of assistance, the business will take the necessary steps to fill the position with another low- and moderate-income employee for two years following the date of assistance.None

Employees working in the business (as of December 31, 2019):

Identify the number of employees

Total:

Business Owner/s:

Fulltime:

Part-Time:

Employees working in the business (as of March 31, 2020):

Identify the number of employees

Total:

Business Owner/s:

Fulltime:

Part-Time:

Total Gross Revenue:

November 2019:

December 2019:

January 2020:

February 2020:

March 2020:

April 2020:

As of this date, has your business received any funding through the Economic Injury Disaster Loan (EIDL), the Paycheck Protection Program (PPP) or other funding source? If you have applied for either or both of the programs and have been denied, please check no.
YesNo

How will you use the Buena Park Grant funds? (Please list out by amount, up to $10,000)

Rent:

Payroll:

Utilities:

Accounts Payable:

Inventory:

Working Capital (Can be no more than 25% of the total):

Total:

Signature

Date

ACKNOWLEDGMENT, AGREEMENT AND CERTIFICATION

Acknowledgement: I/We understand that this grant is being provided by the City of Buena Park based solely upon the information that you have provided in this application. I am also verifying that there are no outstanding tax liens or legal judgments against the business.

Certification: I/We certify that the information provided in this application is true and complete to the best of my 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.

I/We also agree that this application authorizes the City to verify all sources of incomes and/or including, but limited to, the submittal of a request to the Employment Development Department/Unemployment Agency to verify any unemployment benefits currently being received by the business owner.

I/We also agree that this form authorizes the City to verify the business owner(s) Small Business Administration (SBA) loans/ grants received for this business in connection with coronavirus pandemic and/or CARES Act.

By signing below, I certify that the above statements are true and correct to the best of my knowledge. I understand that a false statement may disqualify me from benefits.

Owner Signature

Date

Co-Owner Signature

Date

INFORMATION FOR GOVERNMENT MONITORING PURPOSES

The following information is requested by the Federal Government for certain types of loans and grants related to a dwelling, in order to monitor the Lender's compliance with equal credit opportunity, fair housing, and home mortgage disclosure laws. You are not required to furnish this information, but are encouraged to do so. The law provides that the Lender may neither discriminate on the bases of this information, nor on whether you choose to furnish it. However, if you choose not to furnish it under Federal regulations this Lender is required to note race and sex on the bases of visual observation of surname. If you do not wish to furnish the information, please check the box below. (Lender must review the above material to ensure that the disclosure satisfy all requirements to which the Lender is subject under applicable state law for the particular type of loan applied for). 

Owner

I do not wish to furnish this information
FemaleMale
Race/National Origin: check all that apply:
WhiteBlackAsian or Pacific islanderAmerican Indian or Alaskan nativeOther (specify)
Other:

Ethnicity (please check one):
HispanicNon-Hispanic

Co-Owner

 

I do not wish to furnish this information
FemaleMale
Race/National Origin: check all that apply:
WhiteBlackAsian or Pacific islanderAmerican Indian or Alaskan nativeOther (specify)
Other:

Ethnicity (please check one):
HispanicNon-Hispanic