Fillable Augusta COVID-19 Small Business Relief Program Application (City of Augusta)

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Augusta COVID-19 Small Business Relief Program Application (City of Augusta)

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The Augusta COVID-19 Small Business Relief Program Application (City of Augusta) form is 16 pages long and contains:

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  • 18 check-boxes
  • 95 other fields

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Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
CITY OF AUGUSTA
SMALL BUSINESS RELIEF PROGRAM
BUSINESS INFORMATION
Applicant Business Name:
Doing Business As (DBA):
Applicant/Business owner name(s):
Business Physical Location Address:
Business Mailing Address (if different):
Owner(s) Home Address:
Owner’s Mailing Address (if different):
Business Phone:
Alternate Phone:
Email:
DUNS No.
Get one here or look yours up
https://www.dnb.com/duns-number.html
Date of Incorporation:
Current number
of employees:
Number of employees retained if
business receives relief:
Has the business ever been subjected to criminal or civil fines and penalties including from City of
Augusta code or regulatory violations or in bankruptcy? Is the business or business owner delinquent in
any city, federal, state taxes, child support? Yes No
BUSINESS TYPE: LLC Partnership Sole Proprietor Other
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
Covid-19 Small Business Relief Program Eligibility Checklist:
Is the Business located physically in Augusta-Richmond County, Georgia?
Does the business employ 10 or fewer employees and have less than $500,000 in annual gross revenues at
time of application to the Small Business Loan Program.
Does the business have an active Augusta, Georgia business license? If so, please include proof of
licensure
Does the business have an active DUNS number? If so, please provide proof of DUNS number (above).
Does the business have General Liability Insurance? If so, please provide proof of insurance.
Is the business Current on its tax obligations to the City of Augusta? If so, please include proof of status
from Augusta-Richmond County Tax Commissioner’s Office
a. This can be satisfied by proof of payment of most recently due sales and property tax bills.
Does the business agree to enter into a written Agreement with City of Augusta and agree to provide
documentation for eligibility and reporting confirmation as requested by Housing and Community
Development?
Does the business agree to agree to participate in HUD-mandated Technical Assistance training made
available through HCD? Obligation to complete mandatory Technical Assistance training is a regulatory
requirement.
Does the business agree to comply with the Job Creation or Retention Requirements as set forth in the
Program guidelines?
By checking the boxes above, you are certifying that the responses are current and accurate for the business
applying for Covid-19 Relief Funding. If you answered “No” to any of these questions, your business may not be
eligible for funding under this program. You may contact HCD at 706.821.1797 for additional information and/or
clarification.
NOTE: If at any point in this application you need additional space for your responses, please use a separate document and c learly indicate the title
of the section for which you are providing additional responses.
NOTE: Applicants will be screened through the General Services Administration (GSA), a federal agency, which is required by the Federal
Acquisition Regulation (FAR) to compile and maintain a list of parties debarred, suspended, or disqualified by federal agenci es. Contractors as well
as recipients of federal financial assistance must be registered at Sam.gov. To determine if a proposed contractor is debarre d, grantees should check
the federal SAM database. Active registration in SAM is required to apply for an award and for HUD to make a payment. In addition to checking
the name of the contracting firm, the name of the president and owner of the firm should also be checked. Staff should also r eview any state and
local debarment lists. Website printouts must be placed in the file.
Per the SAM User Guide, the No Active Exclusions field on the SAM Entity summary indicates whether the entity has a current d ebarment.
SAM.gov will check the exclusions list for the DUNS number of your entity and indicate whether any exclusion records exist. If an active exclusion
record exists for your entity, this question will default to “Yes,” meaning that the contractor is debarred. No Record Found means that the entity is
not registered or has let its registration lapse. The entity should ensure that the email address is current in SAM.gov so that when automated
reminders are sent to renew registration each year that this reminder does not go into spam due to an obsolete email address.
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
PROPOSED USES OF FUNDS
AMOUNT OF
REQUEST
USE (i.e. Payroll Expenses, Rent/Mortgage/Lease costs, Utility costs,
etc.)
$
Total Relief Grant Funds Request (Max $5,000):
$
Please specify below the jobs your business intends to retain or create through the funds provided
by the Relief Fund.
Position Title:
Hours Worked per
Week:
Position Title:
Hours per Week:
Please indicate any additional jobs created or retained, in this format, on a separate sheet
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
EMERGENCY NEED
1. Describe the negative impact the COVID-19 pandemic has had on your business. Include the
number of employees that have been laid off, if any.
2. Please use the space below to explain how the funding will help your business remain viable and
prevent layoffs:
3. If applicable, describe how will you create new lines of business and services to meet new
demand during the COVID-19 pandemic and the number of new jobs created:
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
Other Funds
1. Describe your business revenues during the COVID-19 public health emergency compared to a
similar period prior to COVID-19 (submitted financials should support response):
2. Describe other funds you intend to apply for and the amounts and sources of those funds and total
amount (e.g. SBA loan, WEDC SB 20/20f, unemployment insurance benefits, etc.).
3. Indicate if you are receiving any “Business Interruption Insurance” and , if so, the amount.
4. Describe any other gaps in financing you might have to prevent employee layoffs or create new
jobs and your plan to fill those gaps.
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
APPLICANT STATEMENT: I hereby certify that the information on this form is complete and accurate. I understand
that the information provided may be subject to further verification by the City of Augusta. If necessary, I will provide
the information required to verify this data (e.g. payroll records, tax fillings, bank account statements, etc.). I,
therefore, authorize such verification, and I will provide the supporting documentation, if necessary. All parties with
an ownership stake in the firm must agree and sign below as indicated.
SIGNATURE: ____________________________________________________Date: ___________________
Name (please print):_________________________________________________________________________
Title (please print):__________________________________________________________________________
SIGNATURE: ____________________________________________________Date: ___________________
Name (please print):_________________________________________________________________________
Title (please print):__________________________________________________________________________
SIGNATURE: ____________________________________________________Date: ___________________
Name (please print):___________________________________________________________ _______________
Title (please print):___________________________________________________________________________
Please provide signature(s), printed name(s), and title(s) of additional owners on separate page (if applicable).
Please submit copies of these documents along with application
Small Business Relief Grant Application (this document)
Owner Income(s) self-verification form using template in Appendix A of
this document
Owner’s last two years of recently completed IRS Form 1040 (all owners
51% of business or more)
Business Operating Agreement – (for businesses with multiple partners)
Copy of liability insurance (or willing to obtain)
Previous 8 weeks of payroll or other documents showing a history of
employees on payroll as of the application submission date
2020 Q1 Financial Statements (period covering Jan. 1, 2020 to March 31,
2020
Previous Year (2019) Quarterly Financial Statement*, preferably Q1
(period covering Jan. 1, 2019 to March 31, 2019)
If business did not operate in Q1 2019, a different Quarterly
Financial Statement may be submitted to demonstrate the Financial
Loss suffered because of the Covid-19 public health emergency and
resulting economic downturn.
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Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
*A Quarterly Financial Statement is a summary or collection of unaudited financial statements, such
as balance sheets, income statements, and cash flow statements, issued by companies every quarter
(three months). In addition to reporting quarterly figures, these statements may also provide year-to-
date and comparative (e.g., last year's quarter to this year's quarter) results.
NOTE- HCD Staff will follow-up with applicants for required additional information and documents
after application submission, including income self-certification forms for all employees
(Appendix A).
Please email completed applications, with all necessary attachments included to
devans2@augustaga.gov
You May Also Mail or Hand Deliver completed application to:
Augusta Housing and Community Development Department
Attn: Destinye Johnson, CD Coordinator
510 Fenwick Street
Augusta, GA 30901
Questions regarding the process for this application can be directed to Destinye Johnson,
Community Development Coordinator, at djohnson3@augustaga.gov or 706-821-1797.
Questions regarding the content of this application can be directed to Daniel J. Evans,
Community Development Manager, at devans2@augustaga.gov or 706-821-1797.
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
APPENDIX A- Business Owner Income Documentation and Conflict of
Interest Certification
INCOME is defined as the annual gross income (before deductions) of all family and non-family members 18+
years old living in the household. All sources of income must be counted from all persons in the household
based on the anticipated income expected in the next 12 months.
Please circle which box applies to you, the Owner, by matching household size (number of family
members) to income:
Number of
Family Members
in Household
(Select one)
Annual Income
Select Which Household Size and
Income Applies to You
1
$36,900 or less
Above $36,900
2
$42,200 or less
Above $42,200
3
$47,450 or less
Above $47,450
4
$52,700 or less
Above $52,700
5
$56,950 or less
Above $56,950
6
$61,150 or less
Above $61,150
7
$65,350 or less
Above $65,350
8
$69,600 or less
Above $69,600
Please check your ethnicity (pick 1 of 2): Hispanic/Latino Non-Hispanic/Latino
Please check your race (pick 1 of 10 choices):
White
Black or African American
Asian
American Indian/Alaskan Native
Asian & White
American Indian/Alaskan Native & White
Native Hawaii/Other Pacific Islander
Black/African American & White
American Indian/Alaskan Native & Black/African American
Other Multi-Racial
NOTE: This income verification and Conflict of Interest Statement apply to the Principle or majority
owner of the company, representing as the responsible party on behalf of the applying firm.
(Please review the Conflict of Interest Statement on the next page and sign to
acknowledge your agreement and compliance)
Last Edited: June 2020
City of Augusta - CV-19 SB Relief Program Application
APPLICANT CONFLICT OF INTEREST STATEMENT: I hereby declare that any person(s) employed by
the City of Augusta, who has direct or indirect personal or financial interest in this application or in any portion
of the profits that may be derived there from, has been identified and the interest disclosed below. (Please
include in your disclosure any interest which you know of. An example of a direct interest would be a City of
Augusta employee, City of Augusta Commission Member, City of Augusta Community Development Block
Grant Selection Committee, who would be paid to perform services under this proposal. An example of indirect
interest would be a City of Augusta employee who is related to any officers, employees, principal or
shareholders of your firm or to you. If in doubt as to status or interest, please disclose to the extent known). I
hereby certify that the information on this form is complete and accurate. If necessary, I will provide the
information required to verify this data (e.g. pay stubs, bank account statements, etc.). I, therefore, authorize
such verification, and I will provide the supporting documentation, if necessary.
Name: __________________________________________________________________________ (printed)
Signature: ____________________________________________________Date: ___________________
Disclosed Conflict of Interests:
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
____________________________________________________________________________________________________________
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City of Augusta - CV-19 SB Relief Program Application
APPENDIX B
SAMPLE CV-19 SMALL BUSINESS RELIEF PROGRAM
SCORING MATRIX
If the applicant meets all threshold criteria, Selection Committee reviewers will utilize the following project scoring
criteria to evaluate the project for the purposes of making a funding recommendation. Scoring will help determine
priority of project application versus other projects competing for funds. Applications scoring 70 and above will be
eligible to be recommended for funding.
Evaluation Criteria (100-Point Scale + Bonus):
Capacity and Experience to Operate the Business (20 points)
Applicant has the demonstrated capacity to operate the business sustainably.
Consider project status, industry experience, and business development classes and
resources.
Readiness to Proceed (10 points)
The Business has a thoroughly demonstrated proof of concept and clear market
analysis. Proposal includes a clear plan for implementation including a realistic
timeline with set deliverables.
Infectious Disease Response (20 points)
Business will be severely impacted by the policies put into effect due to the
coronavirus pandemic OR business provides a support service and will need
funding assistance to implement new protocols or meet higher demand
Job / Employee retention (30 points)
Proposal ensures employee retention for at least 1 year. Up to 30 Pts awarded
based on Full-Time Equivalent FTE job retention: 30 Pts for 3 or more FTE
positions retained, 20 Pts for 2 or more FTE retained, 10 points for 1 FTE positions
retained, and 0 points for a lower ratio of retained jobs. One FTE position is
defined as 40 hrs. per week, or any combination of part-time positions combining
for 40 hours per week, including owners. 1099 contractors DO NOT count as
employees for job creation purposes.
Minority Business Enterprise or Business Owner is Low-Moderate Income
(10 points)
Project Costs (10 points)
Project costs are reasonable, all other sources of financing committed, grant
resources as not being substituted for other available resources
Application Completeness (5 point BONUS)
Up to 5 bonus points for application with concise descriptions and backup
information, professional writing and accurate math.
Use of City Managed Financing (5 point BONUS)
5 bonus points for business that is not, or has not been, a recipient of City of
Augusta Financial Programs or other City of Augusta HUD funding.
TOTAL
0
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Completed 12 October 2020

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