Fillable CALIFORNIA SMALL BUSINESS COVID-19 RELIEF GRANT PROGRAM Nonprofit (California Small Business COVID-19 Relief Grant Program)

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CALIFORNIA SMALL BUSINESS COVID-19 RELIEF GRANT PROGRAM Nonprofit (California Small Business COVID-19 Relief Grant Program)

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CALIFORNIA SMALL BUSINESS COVID-19 RELIEF GRANT PROGRAM
Nonprofit 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 nonprofit
entity (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 executive director or other
equivalent senior managing officer 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 nonprofit organization pursuant to either Section 501(c)(3),
Section 501(c)(6) or Section 501(c)(19) of the Internal Revenue Code 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 organization. The Applicant acknowledges and agrees that if the Applicant receives a grant
and the Applicant’s organization 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 organization 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 and overhead, including rent, utilities, mortgage principal and interest
payments (excluding mortgage prepayments), and/or debt obligations, including principal and interest,
incurred before March 1, 2020;
(c) costs associated with re-opening the Applicant’s 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;
(e) any 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; or
(f) any other COVID-19-related costs that are not Excluded Expenses (as defined below).
___ 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 (collectively “Excluded 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 officer or
director thereof legally liable, including, but not limited to, liability for possible charges of fraud.
___ 7. The Applicant acknowledges and agrees that the Applicant is not one or more of the following
types of entities deemed ineligible to receive a grant under the Program:
(a) a nonprofit entity not registered as either a 501(c)(3), 501(c)(6) or 501(c)(19);
(b) a government entity (other than an entity owned and/or operated by a Native American tribe)
or elected official office;
(c) a business or organization primarily engaged in political or lobbying activities;
(d) a passive business, investment company or investor who files a Schedule E on its tax returns;
(e) a church or other religious institution, other than a school, child care, or other educational
organization affiliated with a church or other religious institution where (i) greater than 50% of the gross
annual revenue (as reflected on the entity’s most recent tax filing (2019)) is derived from the school, child
care facility or other educational organization and (ii) the Grant Funds will be used only for eligible costs
and expenses directly related to the school, child care, or other educational organization, and no portion
of the Grant Funds will be used for any normal profit or overhead of the church or other religious
institution;
(f) a financial business or organization primarily engaged in the business of lending, such as a bank,
finance company or factoring company;
(g) a business or organization engaged in any activity that is illegal under federal, state or local
law;
(h) a business or organization of a prurient sexual nature, including a business or organization
which presents live performances of a prurient sexual nature or a business or organization 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;
(i) a business or organization 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;
(j) a business or organization that restricts patronage for any reason other than capacity;
(k) a speculative business, meaning a business for the sole purpose of purchasing and holding an
item until the market price increases or other business principally engaged in risky activity for the chance
of an unusually large profit, including but not limited to, (i) oil wildcatting, (ii) dealing in stocks, bonds,
commodity futures, and other financial instruments and (iii) mining gold or silver in other than established
fields; or
(l) a business or organization that is affiliated (as such term is defined in 13 C.F.R. § 121.103) with
another Applicant; or
(l) a business, 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 officer
or board member of the Applicant: (i) has within the prior three-years been convicted of or had a civil
judgment rendered against such officer or 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 executive director or equivalent senior managing officer of the Applicant has applied
for or received, nor will any executive director or equivalent senior managing officer of the Applicant apply
for or receive, any other grant through or under the Program on behalf of any other business and/or
organization for which such person is also an owner, executive director or equivalent senior managing
officer. The undersigned hereby represents and warrants, as the executive director or equivalent senior
managing officer of the Applicant, that the Applicant is the undersigned’s eligible organization 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. Neither the Applicant nor its officers or directors are listed on the sanctions list for the Office of
Foreign Assets Control of the U.S. Department of the Treasury.
___ 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 and the Applicant’s tax return information and other
information related to the Applicant that may be requested by such representatives, which may include
an investigatory background check of the Applicant. 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 tax 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
_________________________________
________________________________________________
Organization Name
EIN #
_____________________________________
Organization Address
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CALIFORNIA SMALL BUSINESS COVID-19 RELIEF GRANT PROGRAM Nonprofit (California Small Business COVID-19 Relief Grant Program)

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Completed 15 April 2021

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