Fillable APPLICATION FORM Clermont County Small Business Relief Program (Clermont County OTCS)

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APPLICATION FORM Clermont County Small Business Relief Program (Clermont County OTCS)

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The APPLICATION FORM Clermont County Small Business Relief Program (Clermont County OTCS) form is 4 pages long and contains:

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  • 58 check-boxes
  • 22 other fields

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File type: PDF

U.S.A. forms for Clermont County OTCS

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APPLICATION FORM
Clermont County Small Business Relief Program
*Businesses will be required to provide documentation to verify data provided in order to be eligible for grants.
*Incorrect or incomplete information will result in disqualification of the businesses.
Is anyone in your immediate family (parent, child, sibling) an employee of Clermont County local
government? YES NO
Is anyone who lives in your household an employee of Clermont County local government?
YES NO
Name of Business:
Physical Address (no P.O. Box):
Number Street
City Zip Code
Mailing Address (if different)
Number Street
City Zip Code
Business Owner Name(s)
Contact Information
Contact Name
Contact Phone
Contact Email
Business Federal Tax ID Number:
DUNS # (optional for this application but required prior to grant award)
Find or Request DUNS#: https://fedgov.dnb.com/webform/displayHomePage.do
Enter North American Industry Classification System (NAICS) for your business:
https://www.naics.com/search
1. Is your business a for-profit entity with a location in Clermont County?
Yes No
2. What type of business entity are you?
Sole Proprietor S Corporation Partnership
C Corporation Limited Liability Company Other
3. Has your business been in operation since January 2020?
Yes No
4. Did your business have less than $2,000,000 in gross revenues/receipts during 2019?
Yes No
5. Select the number of employees and/or 1099 workers (full-time or part-time) on March 22,
2020 from the options below: (NOTE: If you are a sole proprietor, count as 1)
1-10 11-50 51 or more
6. Did your business experience a decrease in gross revenue/receipts/deposits of 35% or more
due to COVID-19 as evidenced by comparing March 1 - April 30, 2019 revenue/receipts/
deposits to March 1 - April 30, 2020 revenue/receipts?
Yes No
7. How much funding is being requested?
$5,000 $10,000
8. Please check all that apply on how the grant funds will be used?
(documentation to demonstrate proof of payment for use of these funds will be REQUIRED at closeout)
NOTE: The following expenses ARE NOT eligible for grant funds: √cost of vehicle or equipment leased or purchased
after March 23, 2020, except if the purchase of equipment is to comply with Responsible RestartOhio; √personal, non-
business expenses of the business or it's owner; √construction costs; √any tax, license, or fee obligations payable to any
governmental entity.
Payroll
Rent (not eligible for businesses that operate out of a personal residence)
Utilities (not eligible for business that operate out of a personal residence)
Materials and supplies related to interruption of business caused by related closures
Personal Protective Equipment or other COVID-19 expenses related to compliance with
Responsible Restart Ohio
Mortgage (not eligible for businesses that operate out f a personal residence)
Other:
Income Replacement - ONLY for Sole Proprietors that can document loss of revenue
from March 1, 2020 - April 30, 2020 SO LONG AS no unemployment benefits are
being or are expected to be received by the applicant.
9. Has your business received or been approved for other Federal Assistance for lost revenue or
expenses arising from the pandemic, including Paycheck Protection Program or Emergency
Disaster Loan?
Yes No
10. Has your business been approved for a business interruption insurance claim as a result of
COVID-19?
Yes No
11. Is your business in compliance will all Federal, State and Local requirements applicable to its
type of business?
Yes No
12. Is your business in the bankruptcy process:
Yes No
13. Are you a type of entity that is required to file with the Ohio Secretary of State?
Yes No
14. Is your business current with all Federal, State, County and Local taxes and fees taking into
consideration any extended due dates due to COVID-19?
Yes No
15. Is your business in good standing with all applicable government regulations related to
building code or property maintenance issues?
Yes No
16. Is your business property a nuisance property for police/fire/EMS calls?
Yes No
17. Is your business of the following?
a) Adult entertainment
b) Bank, savings and loan, credit union
c) E-commerce only
d) Liquor/wine store
e) Vaping store
f) Cannabis dispensary
g) Franchise not locally owned and independently operated
Yes No
18. Summarize the financial and operation impacts that COVID-19 has on your business:
19. Which municipality or township is your business located? (choose one by arrowing up or down)
20. Is your business a Minority Owned Business Enterprise (MBE):
Yes No
21. Is your business a Woman Owned Business Enterprise (WBE)
Yes No
22. Is your business Veteran Owned?
Yes No
City of Milford
City of Loveland
23. Will this grant allow you to retain or create at least 1 job?
Yes No
APPLICANT STATEMENT:
By checking this box, I hereby attest and certify that the information on this form is
complete and accurate. If selected, I will provide ALL supporting documentation required for
verification.
If your business is selected, you will need to provide the following documentation and other documentation
as required:
-- Have been operational since January 2020. This can be evidenced, at a minimum, by: a) filing(s) with the
Ohio Secretary of State, such as articled of incorporation or other registration documents along with an Ohio
Secretary of State Certificate of Good Standing; b) an Ohio vendor's license; c) Federal Schedule C - Profit or
Loss from Business (Sole Proprietorship); or any other documents that demonstrate that the business has been
in operation as a for-profit since January 2020.
-- Have less than $2 million in gross revenue/receipts on an annual basis. This can be evidenced by records
such as the business 2018 and 2019 federal income tax return or any other financial statements or records.
-- Must have experienced a decrease in gross revenue/receipts/deposits of 35% or more due to COVID-19 as
evidenced when comparing March 1-April 30, 2019 revenue/receipts/deposits to
revenue/receipts/deposits for March 1-April 30, 2020. This can be evidenced by financial information/
records, including, at a minimum, bank statements.
-- Have no more than 50 employees or 1099 workers as of March 22, 2020. This can be demonstrated by
forms such as 2019 Form W-3 (Transmittal of Wage and Tax Statement) or 2019 Form 1096 (Annual
Summary and Transmittal of U.S. Information Returns) and payroll reports or checks that evidence number
of workers as of March 22, 2020.
-- Business location in Clermont County, Ohio and the grant funding will be used for expenses for that
business. This can be evidenced by records such as a mortgage statement, utility bill, insurance premium
statement and property tax bills.
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APPLICATION FORM Clermont County Small Business Relief Program (Clermont County OTCS)

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Completed 25 January 2021

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