Community Development Block Grant Application
For Small Businesses
Business Information
Business Name: ________________________________________________________________
Contact Person: _____________________________ Phone:_____________________________
Current Number Full Time Equivalent Positions at date of grant application: _______________
Woman owned business? YES ___ NO ___ Minority owned business? YES ___ NO ___
Is the business Section 3 Certified? YES ___ NO ___
Physical Address: _______________________________________________________________
Lease or Own: _______________________ Home or Commercial Based: __________________
Mailing address: _______________________________________________________________
Website: ____________________________ Email: __________________________________
Use of Grant Funds (Be specific - Attach additional sheets if necessary):
Please describe how your business has been affected by the impact of COVID-19 and
Executive Orders 53. (Attach additional sheets if necessary)
Summary of Costs
Total Grant Funds Requested for COVID-19 Recovery Related Expenses (Limit of $5,000 per business)
Reopening Costs Amount Requested: __________ Rent Relief Amount Requested: __________
Total Amount Requested: _______________
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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Examples of Acceptable Uses of Funds:
Per the grant program guidelines, approvable expenses are those that are directly related to the
reopening of the business per the State of Virginia’s reopening guidelines specific to your
industry. Examples include:
Purchase of protective supplies, tools, equipment, or inventory
Cleaning services or supplies
Property improvements or renovations of a commercial location to accommodate social
distancing and/or outdoor dining, recreation, etc.
Software/Hardware expenses to accommodate delivery, online payments, online
reservations, etc.
Signage, advertising, marketing expenses, etc. to promote that your business is open/
operating under modified conditions, to promote proper distancing/sanitization, etc.
Rent Relief
Please attach the following items to this application:
Copy of 2019 & 2020 City of Poquoson Business Licenses
Completed IRS Form W9
Detailed paid receipts for each service, item or project for which you are requesting
reimbursement. (Bank statements, canceled checks, and/or credit card receipts may also
be acceptable.)