Fillable 4390 State of Oregon COVID-19 Emergency Business Grant Application

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4390 State of Oregon COVID-19 Emergency Business Grant Application

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State of Oregon
COVID-19 Emergency Business
Grant Application
The Oregon Legislature, in partnership with the Governor, allocated $5 Million from the State
General Fund, which will be combined with $5 Million redirected from existing programs at the
Oregon Business Development Department (Business Oregon), for the purpose of providing
financial assistance to small businesses adversely affected by economic conditions associated
with the COVID-19 pandemic that have not received federal emergency assistance under the
federal CARES Act or other federal program for emergency pandemic funding.
To fill gaps not reached by other programs, these state funds are directed to adversely
affected businesses with 25 or fewer employees, and only those that have been unable to
receive federal CARES Act funding, including the Small Business Administration's Paycheck
Protection Program, Economic Injury Disaster Loan Emergency Advance program, or other
federal programs for emergency pandemic funding to date. Businesses may use the proceeds
for any business-related operating expenses.
This application is for a business that meets all of the following eligibility requirements:
The Business is headquartered in Oregon and has its principal operations in Oregon.
If required by Oregon law to be registered with the Oregon Secretary of State to do
business in Oregon, the Business is so registered.
The Business has 25 or fewer employees.
The Business was adversely affected in either one of the following two ways:
o For-profit and non-profit (limited to 501(c)(3) corporations) businesses that were
prohibited from operation as directed by Executive Order 20-12.
o For-profit businesses that can demonstrate a one-month decline in sales greater
than 50% in the month of March 2020 or April 2020 as compared against sales in
the month of January 2020 or February 2020. Those non-profit businesses (limited
to 501(c)(3) corporations) that can demonstrate a decline in revenue greater than
50% across the months of March 2020 and April 2020 as compared against the
same period of time in 2019.
The Business that has been unable to access federal CARES Act funds including:
o The Paycheck Protection Program (PPP);
o Small Business Administrations’ (SBA) Economic Injury Disaster Loan Emergency
Advance program (EIDL); or
o Other federal programs to date for emergency pandemic funding.
The following Businesses are ineligible to apply for or receive funding under the Program:
Passive real estate holding companies and other entities holding passive investments.
Non-profit entities that do not have federal 501(c)(3) status.
Businesses that are delinquent on federal, state or local taxes that were due before April 1,
2020.
Businesses that do not comply with all federal, state and local laws and regulations.
2
Businesses that have already received grant funds through this State of Oregon COVID-19
Emergency Business Grant program.
Businesses that do not otherwise meet the eligibility requirements sets forth above.
Awards to eligible businesses will be made as a grant. The amount of the grant will be the
greater of two figures: first based on the number of employees before the COVID-19 crisis (as
of February 29, 2020); or the second based on the documented amount of fixed operating
expenses for the 60 day period of January 1 through February 29, 2020:
1-5 employees
o $2,500, or
o 60-day fixed expenses up to a maximum of $5,000.
6-10 employees
o $5,000, or
o 60-day fixed expenses up to a maximum of $10,000.
11-15 employees
o $7,500, or
o 60-day fixed expenses up to a maximum of $15,000.
16-20 employees
o $10,000, or
o 60-day fixed expenses up to a maximum of $20,000.
20-25 employees
o $12,500, or
o 60-day fixed expenses up to a maximum of $25,000.
Only employees reported to the Oregon Employment Department on Form 132, for Q4 2019 or
Q1 2020, will be considered eligible when calculating the number of employees.
Business information, ownership information and demographic information will be reported to
the State for all applications submitted, reviewed, approved and/or denied. Information
reported includes, but is not limited to:
o Name of company
o Employer Identification Number (EIN)
o Oregon Business Identification Number (BIN)
o Address of company
o Industry/NAICS
o Amount of award
o Legal business structure
o # of employees as of February 29, 2020
o # of employees expected to be retained as a result of this award
3
Section 1: Business Information
Business Name Business Type
Telephone
Street Address
City State Zip Code County
Employer Identification Number (Federal EIN)
Business Identification Number (issued by Oregon Employment Department)
NAICS Code (as listed on the businesses most recent federal tax filing)
Description of product(s) or service(s) offered:
Section 1A: Business Contact Information
Name Title
Phone Number Email
Select Type
4
Section 2: Business Details
Company Principals
Name Title Percent Ownership
Name Title Percent Ownership
Name Title Percent Ownership
Name Title
Percent Ownership
Total Percent Ownership
Amount requested
How many jobs will be retained at your business as a result of the grant?
(Include jobs lost since February 29, 2020 that can now be retained because of the grant.)
0
5
Number of Employees:
Check one of the boxes below based on employee headcount on February 29,
2020.
o 1-5 Employees
$2,500 (no verification required)
Up to $5,000 (verification of 60 days fixed expenses)
o 6-10 Employees
$5,000 (no verification required)
Up to $10,000 (verification of 60 days fixed expenses)
o 11-15 Employees
$7,500 (no verification required)
Up to $15,000 (verification of 60 days fixed expenses)
o 16-20 Employees
$10,000 (no verification required)
Up to $12,000 (verification of 60 days fixed expenses)
o 21-25 Employees
$12,500 (no verification required)
Up to $25,000 (verification of 60 days fixed expenses)
Verification of Eligible Expenses and Employment (if applicable)
(Check all attached)
Copy of rent/lease agreement
Copy of recent business utility bills
Electricity Water/Sewer Natural Gas
Phone Garbage Broadband
Cell phone Business Mortgage statement
Other:
Oregon Employment Department Form 132
* For businesses with more than 5 employees, provide a copy of Q4 2019 or Q1 2020
Oregon Employment Department Form 132 (redact employee names and Social
Security Numbers)
6
Section 3: Certifications and Representations
The information in this application, including all attachments and certifications, are, to the best
of the knowledge of the undersigned, complete, current and accurate. The application
presents fairly the conditions of the eligibility of the undersigned. Proceeds of the award are
intended to solely support the operations and reopening expenses of the applicant business.
Initial all the following certifications that apply:
o The applicant business was adversely impacted as a direct result of
the COVID-19 crisis.
o The applicant business had 25 or fewer employees as of February 29,
2020.
o The applicant business:
Was determined to be a non-essential business in accordance
with Governor’s Executive Order 20-12, or
Experienced a 50% or more reduction to sales as a result of the
COVID-19 crisis.
o The applicant has not received federal financial funding relief through
the CARES Act of 2020 (Paycheck Protection Program or Emergency
Injury Disaster Loan assistance program) or any subsequent federal
act that provides emergency pandemic funding as of the date of
application.
o The applicant business is current on all federal, state and local taxes
as of the date of application.
o The applicant business is headquartered in and has primary operations
in Oregon.
o The applicant business is currently registered with the Oregon
Secretary of State to do business in Oregon if such registration is
required.
o The applicant business is compliant with all federal, state and local
laws.
o The applicant business agrees to provide business, financial and
ownership information necessary to determine and verify eligibility.
o The applicant business will only use these proceeds to support
business-related expenses to maintain operations and/or reopen and
that Oregon COVID-19 Emergency Business Grant Program proceeds
will not be used for personal purposes.
o Unless otherwise directed by Executive Order, the applicant is open, or
has reopened for business.
7
Failure to comply with eligible use of proceeds, or making a material
misrepresentation about the business and its operations to qualify for an award will
be a provision of default of the award and subject the award to recapture. The
State of Oregon reserves the right to request additional documentation from the
applicant to verify the accuracy and authenticity of the information provided.
Should the State determine a misrepresentation exists creating a default, the
award may be forfeited and subject to repayment. Failure to repay or cure a
default will result in any and all collection actions permissible by law, including
through third party collection services or the Oregon Department of Revenue. The
applicant agrees to allow the State to pursue such collection actions.
As these funds are being provided by the State of Oregon, Business Oregon and
affiliated state agencies may use your company in future promotions of their
programs and services.
General Certification
I certify to the best of my knowledge that all information, contained in this application, including
all attachments and certifications, is valid and accurate. I further certify that, to the best of my
knowledge:
1. The application has been reviewed and approved by the authorized owner(s), managers
with appropriately delegated authority, and/or in accordance with the organization’s articles of
incorporation, articles of organization or bylaws, and
2. Signature authority is verified.
Check one:
Yes, I am authorized to submit on behalf of the applicant within authority granted in the
applicant’s articles of incorporation, articles of organization or bylaws. (e.g., President,
Secretary, Chief Executive Officer, Board Chair, etc.)
No, I am not authorized to submit on behalf of the applicant within authority granted in
the applicant’s articles of incorporation, articles of organization, or bylaws so I have
attached documentation that verifies my authority to sign on behalf of the applicant.
The department will only accept applications with proper signature authority
documentation.
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4390 State of Oregon COVID-19 Emergency Business Grant Application

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Completed 12 July 2020

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