Fillable COB Small Business Emergency Grant Application Web Page Version-JBEdits060520

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COB Small Business Emergency Grant Application Web Page Version-JBEdits060520

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The COB Small Business Emergency Grant Application Web Page Version-JBEdits060520 form is 5 pages long and contains:

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  • 34 check-boxes
  • 51 other fields

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File type: PDF

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City of Binghamton Small Business COVID-19
Emergency Grant Program Application
Legal Name Of Business Entity:
Business Owner's Name:
Contact Person:
Contact Person Title:
Business Address:
(The physical location of the business must be located within the City of Binghamton
Email Address:
Phone Number:
What is the Legal Status of your business? (Select from list)
Business Employer Identification Number:
Business DUNS Number:
Reason for which COVID-19 funding is requested:
Amount of COVID-19 Funding Requested:
Briefly describe the nature of your business:
Staffing levels as of January 1. 2020, including owner:
# F/T Emp.
Staffing levels as of March 31, 2020, including owner:
# F/T Emp.
# P
/
T
Emp.:
# P/T Emp.:
(If no, your business is not eligible for this funding.
Do you anticipate that your business will be operational 3 months following award?
Between March 22, 2020 and the date of this application, has your business been closed due to COVID-19?
What is the current status of your business? Are you currently operational?
If open, have the hours of operation been reduced?
If yes, please provide an explanation:
Is the primary address for your business a residential address?
Yes
No
Yes
Yes
No
Yes
No
No
(If yes, your business is not eligible for funding under this program)
How long has your business been in operation?
(Your business must have been in operation before March 1, 2020 to be eligible for funding
You will be required to provide evidence that your business revenues have been affected by COVID-19. If selected for a grant,
you will need to provide documentation showing that for the period March 1, 2020 through May 31, 2020, your revenue
decreased more than 25% over the same period in 2019.
Did your business experience at least a 25% decline in revenue between March 1, 2020 and May 31, 2020?
Yes
No
Choose One
Funding is requested for the following categories (Check all that apply) Estimate amount for a 3-month period:
Rent for business location
Mortgage for business location
Property insurance for business location
Gas Service for business location
Electric Service for business location
Water/Sewer Service for business location
Property Taxes for business location
Cost of Personal Protective Equipment
Replacement of perishable goods
Cost of goods required for takeout service
Cost of COVID related cleaning supplies
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Amount
Provide details for all other potential COVID-19 related funding sources that you applied for or plan to apply for
Grant Program
Paycheck Protection Program (PPP)
Economic Injury Disaster Loan (EIDL)
Federal Emergency Management Agency (FEMA)
New York Forward Loan Program
Community Foundation For South Central NY
Broome Funders Alliance
United Way of Broome County
Amount Requested
Amount Received
Other:
Other:
Please note that funding for the City's grant program cannot duplicate awards made by other Federal, State, other
government entities, or local private organizations or foundations.
Applicant/Owner Information
Owner Race (Select from list):
Owner Ethnicity:
Do you provide health insurance to your employees?
Is the business Certified by New York State as a minority-owned business?
Is the business Certified by New York State as a woman-owned business?
Hispanic
Not Hispanic
Yes
No
Yes
No
Yes
No
Is the applicant an employee of the City of Binghamton?
If yes, list Department and Title:
Does the applicant have a family tie, as defined below, to a current City of Binghamton employee or official?
“Family tie" means a person who is related to any public official or public employee, whether by blood, adoption or
marriage, as any of the following: father, mother, son, daughter, brother, sister, grandfather, grandmother, grandson,
granddaughter, father-in-law, mother-in-law, brother-in-law, sister-in-law, son-in-law, daughter-in-law, stepfather,
stepmother, stepson, stepdaughter, stepbrother, stepsister, half-brother or half-sister.
If yes, list the name and relationship to City employee:
Yes No
Yes
No
Choose One
City of Binghamton COVID-19
Small Business Emergency Grant Program
Certification Form
1. I certify that I own/co-own the for-profit business entity that is the subject of this application.
2. I certify that all information contained in this application and all supporting documentation is true and
complete. I made no misrepresentation, nor did I omit any pertinent information. I fully understand that it is a
federal crime, punishable by fine or imprisonment, or both to knowingly make any false statements when applying
for federal assistance, as applicable under the provisions of Title 18, United States Code, Section 1001, et seq.
3. I certify that I am current with all federal, state, and city taxes owed prior to March 22, 2020.
4. I certify that any CDBG assistance received in 2020 shall be declared on my business’s 2020 federal and state
tax returns, as applicable and in accordance with IRS and New York State Department of Taxation and Finance
regulations and guidance.
5. I certify that, to the best of my knowledge, my business is in compliance with all federal and state laws and
legislation, including regulations dealing with equal employment opportunity.
6. I grant the City of Binghamton the right to independently verify any or all of the information herein, and
understand that the City may refuse to approve the application or may revoke a commitment made if there is any
material misrepresentation in the application, including attachments thereto.
7. I authorize disclosure of information submitted in connection with this application to any government
agency (federal, state, or local), quasi-governmental agency, and other third parties providing COVID-19
assistance, including, but not limited to, the U.S. Small Business Administration (SBA), and the Federal Emergency
Management Agency (FEMA).
8. I certify that no more than one complete application for CDBG assistance shall be made by me as a business
owner in 2020, and no more than one complete application for CDBG assistance shall be made on behalf of the
business that is the subject of this application in 2020, unless this restriction is explicitly waived in writing by the
City.
9. I certify that I will complete brief business update reports at the end of each quarter for one year after
receipt of CDBG assistance.
10. I certify that neither I, nor my co-owners, nor my business are parties to litigation against the City.
11. I certify that to date, I have not received monies or award/approval from the Economic Injury Disaster
Loans (EIDL) or the Paycheck Protection Program (PPP) or other federal sate or local grant programs that are not
already listed on this application.
12. I certify that I am I am not a full-time student.
13. I certify that I received the attached Public Disclosure Notification.
Date:
Owner Name
Signature
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signature
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City of Binghamton COVID-19
Small Business Emergency Grant Program
Public Information Disclosure Notification
Applicants are advised that any and all records (documents, correspondence, memoranda, etc.), regardless of the form
provided, received or maintained by City, may be a matter of public record and subject to release under the U.S. Freedom
of Information Act (FOIA). The City does however, have the right to redact any information which is exempt under the
statute before releasing the documents. The exemptions that would most pertain to financing or grant applications
include, but are not limited to, personal financial information, trade secrets, and commercial and financial information
which is privileged or confidential.
As such, the City suggests that any portion of the application or materials provided by the applicant that contains such
information (including for example, customer lists, processes, etc. or financial information) be clearly labeled with a
legend or marking such as "Confidential information -- Not Public Record". This does guarantee that the information so
marked will necessarily be exempt from public release, as the City will make any final determination about which
information is to be made available to the public, this will be helpful in identifying any records which may be exempt.
I have read and understand this notification
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COB Small Business Emergency Grant Application Web Page Version-JBEdits060520

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Completed 11 July 2020

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