Applicant Certifications for the COVID-19 Relief Statewide Small Business Assistance Program:
Applicants will be required to self-certify adherence to the following:
Pennsylvania CDFI Network Reliance on Business Applicant Certifications for the COVID-19 Relief Statewide Small Business Assistance Program:
____ The Pennsylvania CDFI Network may rely on applicant certifications for use of funds, business eligibility, owner information and financial information for both
the business and the owner. Applicant must make this certification in good faith, taking into account their current business activity and their ability to access other
sources of liquidity sufficient to support their ongoing operations in a manner that is not significantly detrimental to the business.
____ Applicant understands that the grant funds available under the COVID-19 Relief Statewide Small Business Assistance Program are limited, and thus, certain
small business owners, including small business owners who may otherwise qualify for such grant funds, may not be selected to receive grant funds under the
COVID-19 Relief Statewide Small Business Assistance Program. The grant funds shall be awarded by priorities established by the Pennsylvania CDFI Network.
An authorized representative of the applicant must certify in good faith to all of the below:
Businesses receiving grant funds must certify such compliance under penalty of perjury and fines pursuant to 18 Pa. C.S. § 4904 (relating to unsworn falsification to
authorities) to all of the below:
:
____ 1.
The business was in operation on February 15, 2020 and, if required, paid income taxes to the state and federal government, as reported on individual or
business tax returns.
____ 2. COVID-19 has had an adverse economic impact and makes this grant request necessary to support the ongoing operations of the applicant.
_
___ 3. The grant will be used only to cover COVID 19 related costs. I understand that if the funds are knowingly used for unauthorized purposes, the state and
federal government may hold me legally liable such as for charges of fraud.
____ 4. During the period beginning on June 1, 2020 and ending on December 31, 2020, the business has not and will not receive another grant under the COVID-
19 Relief Statewide Small Business Assistance Program.
____5. The business must have been, and remain, in compliance with all relevant laws, orders, and regulations during the period of the COVID-19 disaster
emergency under the Pennsylvania Governor’s proclamation dated March 6, 2020, and any and all subsequent renewals. The foregoing includes, but is not limited to,
orders by the Governor, Secretary of Health, or other commonwealth officials empowered to act during the emergency. Any non-compliant business will be ineligible
for funding under this program and may be required to return all, or a portion, of the funds awarded.
____ 6. I understand that I am ineligible to receive funding under this COVID-19 Relief Statewide Small Business Assistance Program if I, or any owner of 20 percent
or more of the equity of the applicant is incarcerated, on probation, on parole; presently subject to an indictment, criminal information, arraignment, or other means
by which formal criminal charges are brought in any jurisdiction; or has been convicted of a felony involving fraud, bribery, embezzlement, or a false statement in a
loan application or an application for federal financial assistance within the last five years or any other felony within the last year.
____ 7. By executing this application, I am hereby authorizing Pennsylvania CDFI Network and its authorized representative (Lendistry) under the COVID-19 Relief
Statewide Small Business Assistance Program to request access to, and review of, the applicant’s Pennsylvania state tax returns and tax return information. I hereby
warrant that I am an authorized representative of the applicant and have full authority to waive confidentiality under Pennsylvania law and authorize release of this
information. I authorize the Pennsylvania Department of Revenue (the “Department”) to release confidential information in the possession of the Department,
including but not limited to methods such as phone discussions, mail, facsimile, e-mail or other electronic means, and release the Department from liability for said
disclosure.
____ 8. I further certify that the information provided in this application and the information provided in all supporting documents and forms is true and accurate
in all material respects. I understand that knowingly making a false statement to obtain a grant from the State of Pennsylvania is punishable under state and federal
law, including under 18 USC 1001 and 3571 by imprisonment of not more than five years and/or a fine of up to $250,000; under 15 USC 645 by imprisonment of not
more than two years and/or a fine of not more than $5,000; and, if submitted to a federally insured institution, under 18 USC 1014 by imprisonment of not more than
thirty years and/or a fine of not more than $1,000,000.
____9. I acknowledge that the Pennsylvania CDFI Network will confirm the eligible grant amount using tax documents I have submitted. I affirm that these tax
documents are identical to those submitted to the Internal Revenue Service. I also understand, acknowledge, and agree that the Pennsylvania CDFI Network and its
authorized representatives can share the tax Information with state and federal authorized representatives for the purpose of compliance with federal and state
grant requirements and reviews.
____10. I acknowledge that the business must adhere to all applicable federal and state anti-discrimination statutes, regulations and laws including the
Pennsylvania Human Relations Act, the Pennsylvania Labor Relations Act and the federal Civil Rights Act of 1964. Any non-compliant business will be ineligible for
funding under this program and may be required to return all, or a portion, of the funds awarded.
______________________________________
Signature
______________________________________
Print Name
______________________________________
Date
______________________________________
Title
_
_____________________________________
EIN #
________________________________________________
Business Name
_______________________
_________________________
Business Address
________________________________________________
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