Certifications and Signatures:
I understand that all approved items must have been purchased/paid after the Governor of
Virginia declared the COVID-19 emergency (March 13, 2020) and before June 22, 2021. All
reimbursement requests must be made no later than June 22, 2021 or approved funds will be
forfeited. I agree to submit copies of all paid invoices/receipts and copies of all required permits
and approvals in order to receive approved grant funds. I understand that grant funds will be
awarded on a first-come, first-served basis and that applications may be evaluated based on the
following criteria, at the discretion of the City of Poquoson, their staff representatives, and/or the
COVID-19 Small Business Grant Review Board:
proposed use of the grant funds & the extent to which the request is COVID-19
recovery related
extent to which my business was affected by the COVID-19 pandemic and
Virginia’s Executive Orders 53
current number of employees at grant application date
I certify that I have read and understand the City of Poquoson COVID-19 Small Business
Grant requirements and that the information contained herein is true, complete and correct to the
best of my knowledge. I certify that this business is currently open for business in some capacity
as of this application date. I certify that I have authority to apply for this grant on behalf of the
business described herein. I understand that this information may be made available for public
review and is subject to the Virginia Freedom of Information Act.
By signing below, I agree that the grant will be used for business purposes only, and not
for household, personal, or consumer usage. I understand that any willful misrepresentation on
this application and any other grant related documents could result in a requirement to repay
grant funds and/or a violation of Local, State and/or Federal code.
I (Applicant) hereby confirm that ________________________________ is currently
a licensed business located in City of Poquoson and that said business is not a corporately-
owned national chain. I certify that my company currently employs less than twenty (20)
full time equivalent employees. I confirm that I have not received funding from any other
local, state, or federal assistance program for the same expenses I am requesting
reimbursement for on this application under this City of Poquoson program. Lastly, I
certify that my company is current with all local taxes, licenses, permit fees, etc. and that
my company is in compliance with all City of Poquoson ordinances.
Signature: ____________________________________________________
Printed Name: _____________________________________________________
Title: _____________________________________________________
Date: _________________________
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