CALIFORNIA SMALL BUSINESS COVID-19 RELIEF GRANT PROGRAM
Applicant Certifications
In connection with the California Small Business COVID-19 Relief Grant Program (the “Program”) funded
by the State of California (the “State) and administered by the California Office of the Small Business
Advocate (“CalOSBA”) within the Governor’s Office of Business and Economic Development (“GO-Biz”)
the undersigned, constituting an authorized representative of the below-referenced applicant business
(the “Applicant”), acknowledges and agrees, on behalf of the Applicant, that the State, CalOSBA, GO-Biz
and B.S.D. Capital, Inc. dba Lendistry (“Lendistry”), as the designated intermediary of the Program, each
may rely on the below certifications in determining the Applicant’s eligibility for the Program and receipt
of a grant under the Program.
The undersigned further acknowledges and agrees that if (i) any of the following certifications are untrue,
(ii) the Applicant knowingly makes any false or misleading statement or material omission in the
information or materials required or requested from the Applicant, or (iii) the Applicant uses any grant
funds for any unauthorized purpose, the State, CalOSBA, GO-Biz and/or Lendistry may require the
Applicant to repay such grant funds or take any other legal or equitable recourse available, including,
without limitation, by seeking remedies for fraud.
By executing this document, the Applicant hereby certifies to all of the following (please initial next to
each of the certifications below):
___ 1. The undersigned signatory is a duly authorized representative and owner of the Applicant and has
full authority to make the certifications referenced herein on the Applicant’s behalf.
___ 2. The Applicant is currently an active business operating since at least June 1, 2019. The Applicant is
currently operating or has a clear plan to re-open once the State of California permits re-opening of the
business. The Applicant acknowledges and agrees that if the Applicant receives a grant and the Applicant’s
business ceases to operate, the Applicant may be subject to return of all or any portion of such grant.
___ 3. The Applicant has a principal office in the State of California and, subject to the certification made
in (2), above, is presently operating in the State of California.
___ 4. The Applicant’s business has been adversely impacted by COVID-19 and the health and safety
restrictions have resulted in business interruptions, business closures, or similar impacts incurred as a
result of the COVID-19 pandemic, making the grant request made in the Applicant’s application necessary
to support the ongoing operations of the Applicant.
___ 5. If a grant is received by the Applicant, such grant funds will be used only to cover one or more of
the following costs and/or expenses of the Applicant:
(a) employee expenses including payroll costs, health care benefits, paid sick, medical, or family
leave, and insurance premiums;
(b) working capital, overhead (including rent, utilities, mortgage principal and interest payments
(excluding mortgage prepayments)), and/or debt payments (principal and interest) incurred before March
1, 2020;
(c) co
sts associated with re-opening the Applicant’s business operations after being fully or
partially closed due to state-mandated COVID-19 health and safety restrictions and business closures;
(d
)
costs associated with complying with COVID-19 federal, state or local guidelines for reopening
with required safety protocols, including but not limited to equipment, plexiglass barriers, outdoor dining,
PPE supplies, testing, and employee training expenses; or
(e
) an
y other COVID-19 related expenses not already covered (for the same period) through
grants, forgivable loans or other relief through federal, state, county or city programs.
___ 6. If a grant is received by the Applicant, no portion of the grant funds will be used for any purposes
other than those listed in (5) above. Specifically, no portion will be used for the following costs and/or
expenses: (a) human resource expenses for the State share of Medicaid; (b) employee bonuses or
severance pay; (c) tax payments; (d) legal settlements; (e) personal expenses or other expenses unrelated
to COVID-19 impacts; (f) expenses for repairs from damage covered by applicable insurance; or (g)
reimbursement to donors for donated items or services. The Applicant acknowledges and agrees that if
all or any portion of the grant funds are used for any unauthorized purposes, the State of California may
hold the undersigned, the Applicant and/or any other owner thereof legally liable including for possible
charges of fraud.
___ 7. The Applicant acknowledges and agrees that the Applicant is not one or more of the following
types of businesses deemed ineligible to receive a grant under the Program:
(
a
) a g
overnment entity (other than an entity owned and/or operated by a Native American tribe)
or elected official office;
(b
) a b
usiness primarily engaged in political or lobbying activities
;
(c) a passive business, investment company or investor who files a Schedule E on its tax returns;
(d
) a c
hurch or other religious institution;
(e
) a fin
ancial business primarily engaged in the business of lending, such as a bank, finance
company or factoring company;
(f
) a b
usiness engaged in any activity that is illegal under federal, state or local law;
(g
) a b
usiness of a prurient sexual nature, including a business which presents live performances
of a prurient sexual nature or a business which derives directly or indirectly more than de minimis gross
revenue through the sale of products or services, or the presentation of any depictions or displays, of a
prurient sexual nature;
(h
) a b
usiness engaged in any socially undesirable activity or activity that may be considered
predatory in nature such as rent-to-own businesses or check cashing businesses;
(i
) a b
usiness that restricts patronage for any reason other than capacity;
(j) a speculative business;
(k
) a b
usiness that is affiliated (as such term is defined in 13 C.F.R. § 121.103) with another
Applicant; or
(l) a b
usiness, franchise or location of which the undersigned has already applied for and received
a grant under the Program.
___ 8. The Applicant understands that it is ineligible to receive a grant under the Program if any owner of
greater than 10% of the equity interest in the Applicant: (i) has within the prior three-years been convicted
of or had a civil judgment rendered against such owner, or has had commenced any form of parole or
probation (including probation before judgment), for (A) commission of fraud or a criminal offense in
connection with obtaining, attempting to obtain, or performing a public (federal, state or local)
transaction or contract under a public transaction, (B) violation of federal or state anti-trust or
procurement statutes, or (C) commission of embezzlement, theft, forgery, bribery, falsification or
destruction of records, making false statements, or receiving stolen property; or (ii) is presently indicted
for or otherwise criminally or civilly charged by a government entity, (federal, state or local) with
commission of any of the offenses enumerated in subparagraph (i) above.
___ 9.
The Applicant has not and will not apply for or receive any other grant through or under the
Program. Further, no majority owner of the Applicant has applied for or received, nor will any majority
owner of the Applicant apply for or receive, any other grant through or under the Program on behalf of
any other business for which such person is also a majority owner. The undersigned hereby represents
and warrants, as the owner of the Applicant, that the Applicant is the undersigned’s eligible business with
the highest gross revenue. The Applicant agrees that if a second award is issued, then one or both awards
will be voidable at the discretion of the State, CalOSBA, GO-Biz and/or Lendistry, as applicable.
___ 10. The Applicant acknowledges and agrees that, if the Applicant is representing itself as being
women-owned, veteran-owned or owned by one or more of the following racial or ethnic groups (as
indicated on the Applicant’s application) (i) African American/Black, (ii) Asian, (iii) Native American or
Alaska Native, (iv) Native Hawaiian or Pacific Islander, or (v) LatinX/Hispanic for the purposes of
establishing status as underserved for a grant under the Program, then, in each case, at least 51% of the
Applicant’s business must be owned by such persons and at least 51% of the Applicant’s business must be
run on a daily basis by such persons to satisfy such priority requirement. The Applicant, in reliance on the
foregoing grant priority, certifies that it meets the foregoing priority requirements. (Please initial if the
Applicant is either relying on the foregoing priority requirement or if the foregoing priority requirement
is inapplicable to the Applicant.)
___ 11. The undersigned, on behalf of the Applicant, hereby authorizes the State of California and its
designated authorized representatives, including without limitation CalOSBA, GO-Biz and Lendistry, to
request access to, and to review, the Applicant, the Applicant’s tax return information and other
information related to the Applicant and its owners that may be requested by such representatives, which
may include an investigatory background check of the Applicant or its owners. The Applicant
acknowledges that Lendistry will confirm the Applicant’s eligibility for the Program and the eligible grant
amount thereunder based, in part, on the tax and other documents provided by the Applicant, and the
State of California, CalOSBA and GO-Biz may rely on such confirmation and tax and other documents in
making a grant to the Applicant. The Applicant further affirms that the tax return information provided in
connection with the Program is identical to the tax return information submitted to the Internal Revenue
Service. The Applicant understands, acknowledges and agrees that the State of California and its
authorized representatives, including without limitation CalOSBA, GO-Biz and Lendistry, may share such
t
ax information with local, state and federal authorized representatives, including without limitation for
the purpose of compliance with federal, state, or local laws and regulations.
___ 12. Any and all information provided by or on behalf of the Applicant, including without limitation the
information contained in the Applicant’s grant application submitted for the Program and any and all
information provided in support of Applicant’s application under the Program is and will be true and
accurate in all material respects.
___ 13. The Applicant acknowledges that the State of California, CalOSBA, GO-Biz and Lendistry are each
relying upon the certifications made in this document in addition to any other certifications made by the
Applicant in connection with its application for the Program. The Applicant further acknowledges and
agrees that all certifications made by the Applicant in connection with the Program are made in good
faith.
______________________________________
Signature
_____________________________________
Print Name
__________________________________
Date
_________________________________
Title
_________________________________
________________________________________________
Applicant Business Name
EIN #/SSN #/ITIN #
____
_________________________________
Applicant Business Address