Fillable COVID-19 Florida Emergency Bridge Loan Application - April 2020

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COVID-19 Florida Emergency Bridge Loan Application - April 2020 (20200323) Disaster Event: COVID-19 Application Deadline: May 8, 2020

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1 P a g e 20200323 COVID-19
SMALL BUSINESS EMERGENCY
BRIDGE LOAN APPLICATION
Disaster Event: COVID-19
Application Deadline: May 8, 2020
LOAN AMOUNT REQUESTED:
$50,000 maximum. Loans of up to $100,000 may be made in
special cases as warranted by the need of the business.
APPLICATION DATE:
☐ Economic Injury (Loss of Sales or Revenues)
Attach written justification of economic loss or injury caused as a result of or period declared disaster, e.g. sales or inco
me compared to previous
year compared to current period.
EXPECTED SOURCE OF REPAYMENT:
☐ SBA Disaster Loan(s) ☐ Other Federal Aid ☐ Insurance Proceeds ☐ Bank or Other Loan
ONLY ELIGIBLE AND COMPLETED APPLICATIONS WITH
REQUIRED SUPPORTING DOCUMENTATION WILL BE ACCEPTED.
PLEASE READ ENTIRE FORM BEFORE SUBMITTING
For assistance with completing the application, contact the Florida Department of Economic Opportunity
toll-free at (833) 832-4494.
Submit the completed application and required documents by mail or courier to:
Florida Department of Economic Opportunity
C/O Small Business Emergency Bridge Loan
107 E. Madison Street, MSC-160
Tallahassee, FL 32399-4120
2 P a g e 20200323 COVID-19
SECTION I. APPLICATION SIGNATURE
The undersigned, by signature on this document, verifies that information contained herein and in all attachments and all
supporting documents and materials are true and complete, that I/we have authority to apply for this loan on behalf of the
business, and intend to repay the loan using funds available to myself/us or the business that will be used to repay the loan.
The undersigned understands that Florida First Capital Finance Corporation, and/or other financial institutions assisting the
Corporation in i
ts administration of this loan program for the State of Florida, may investigate the credit of the applicant or co-
applicants for purposes limited to this application, and hereby authorized such investigation.
APPLICANT(S) SIGNATURE(S)
APPLICANT 1 (16A)
APPLICANT 2 (16B)
Print Name
Print Name
Signature
Signature
Date
Date
APPLICANT 3 (16C)
APPLICANT 4 (16D)
Print Name
Print Name
Signature
Signature
Date
Date
SECTION II. ELIGIBILITY
YOUR BUSINESS MUST BE:
1. A for-profit, privately held small businesses that maintains a place of business in the state of
Florida and established prior to March 9, 2020.
2. A small business in a designated county in Florida. Eligible Florida counties per Executive
Order 20-52 are: All Counties – Statewide.
3. A small business with 2 to 100 employees.**
4. Must have paid in full previous loans received from the state emergency bridge loan program.
Any outstanding bridge loan must be repaid in full prior to application submission for this event.
**Employees are defined as individuals who receive paid wages or salary which employment taxes (e.g. FICA, FUTA) and income taxes are withdrawn and remitted
to the IRS, as evidenced by business tax returns filed, i.e. IRS Form 940, Employer’s Annual Federal Tax Return, IRS Form 941, Employer's Quarterly Federal Tax
Return or IRS Form W-3, Transmittal of Wage and Tax Statements. For purposes of eligibility, independent contractors (also known as 1099 employees) do qualify
ALL OF THE ABOVE MUST BE TRUE TO BE ELIGIBLE FOR THIS PROGRAM.
INELIGIBLE BUSINESSES:
1. A business deriving more than one-third of gross annual revenue from legal gambling activities.
2. A business engaged in any illegal activity.
3. A business that presents live performances of an indecent sexual nature or derive directly or
indirectly more than 2.5 percent of gross revenues through the sales of products and services,
or the presentation of any depictions or displays, of an indecent sexual nature.
4. A business that has a primary purpose of facilitating polyamorous relationships.
5. Massage parlors.
6. Hot tub facilities.
7. Escort services.
as employees for this loan program.
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3 P a g e 20200323 COVID-19
INELIGIBLE BUSINESSES DO NOT QUALIFY FOR THIS LOAN PROGRAM.
INTEREST RATES:
• Loans will be interest free for the term of the loan (1 year).
• Interest rate will be 12% per annum on the unpaid balance thereafter, until the loan balance is
repaid in full.
LOAN DEFAULT NOTICE:
Each loan must be repaid in full by the maturity date established in the loan promissory note. Any loan not repaid in
full on or before the maturity date will be considered in default. A defaulted loan will incur interest and may be
assigned to a collection agency. In the event of default, the borrower will be responsible for the full amount of the
loan principal, interest, and collection agency fees.
SECTION III. REQUIRED APPLICANT DOCUMENTATION
REQUIRED LOAN APPLICATION DOCUMENTS:
1) Section III of this application form completed and signed by individual(s) who, individually or collectively, own fifty-one
percent (51%) or more of the equity of the business, as evidenced by the businesses tax statements.
2)
Business Tax Returns – At a minimum, copies of the previous two years federal income tax returns for the applicant
business, including all schedules. If available, provide a written explanation.
o Sole Proprietorship – Form 1040, US Individual Income Tax Return, Sch. C, Profit or Loss from Business
o Partnerships – Form 1065, U.S. Return of Partnership Income, Schedule K-1, Partners Share of Income,
Deductions and Credits
o Corporations – Form 1120, U.S. Corporation Income Tax Return
o
S Corporations – Form 1120S, U.S. S-Corporation Income Tax Return
Note: Limited Liability Company (LLC) – IRS will treat an LLC as either a corporation, partnership, or as part of the LLC’s owner’s tax return (a
“disregarded entity”). Specifically, a domestic LLC with at least two members is classified as a partnership (Form 1065) for federal income tax
purposes unless it files Form 8832 and affirmatively elects to be treated as a corporation (Form 1120 or 1120S). And an LLC with only one
member is treated as an entity disregarded as separate from its owner for income tax purposes (Form 1040, Schedule C).
3)
Employer Tax Documentation (one of the following)
o IRS Form 941 - Employer's Quarterly Federal Tax Return (minimum of one from the previous four quarters)
o IRS Form W-3 - Transmittal of Wage and Tax Statements (previous year)
o IRS Form W-2s and/or IRS Form 1099-MISC for a minimum of 2 employees
4) Individual Tax Returns: At a minimum, copies of the previous two years federal income tax returns (IRS Form 1040 and
all schedules) for each individual business owner that signed this application form.
COLLECT ALL REQUIRED SUPPORTING DOCUMENTS BEFORE COMPLETING APPLICATION.
APPLICANT MAY VOLUNARILY PROVIDE ADDITIONAL INFORMATION THAT WILL ADD CONTEXT AND ASSIST THE
LOAN COMMITTEE IN MAKING AN INFORMED LOAN DECISION. ADDITIONAL INFORMATION MAY INCLUDE:
•
Year-end financial statements for the past 2 tax years.
•
Interim financial statements (profit & loss) for the current year-to-date.
•
Additional filing requirements providing monthly sales figures.
•
Explanation of credit report concerns and issues.
ADDITIONAL INFORMATION MAY BE REQUESTED BY THE LOAN COMMITTEE TO DETERMINE A LOAN
DECISION. IF REQUESTED, PLEASE PROVIDE ADDITIONAL INFORMATION WITHIN 7 DAYS OF THE REQUEST.
4 P a g e 20200323 COVID-19
SECTION IV. APPLICATION FORM
1. ORGANIZATION TYPE:
☐ Sole Proprietorship ☐ Partnership ☐ Corporation ☐ S-Corporation
☐
Limited Liability Company Other:
2. BUSINESSES LEGAL NAME: (verified by Sunbiz.org)
3. TRADE NAME: (if different than legal name)
4. EIN (EMPLOYER IDENTIFICATION NUMBER):
5. REEMPLOYMENT ASSISTANCE TAX NUMBER
(RA):
6. MAILING ADDRESS:
☐
Business
☐
Home
☐
Temp
☐
Other
Number, Street, and/or Post Office Box:
City
County
State
Zip Code
7. BUSINESS PROPERTY ADDRESS(ES)
Number and Street
1. DO YOU:
☐ Own
☐
Lease
City
County
State
Zip + 4
9. PRIMARY BUSINESS ACTIVITY:
10.NUMBER OF EMPLOYEES AND AVERAGE WAGE:
(pre-
disaster)
11. DATE BUSINESS ESTABLISHED:
(MM/YYYY)
12. BUSINESS FINANCIAL SUMMARY
2018 2019
2020
(if available)
Gross Revenues
Total Employment/Payroll Expense
Pre-Tax Profit
13. CREDIT INFORMATION
Business Bank (Primary)
Contact Name (if any)
5 P a g e 20200323 COVID-19
Account Type (Checking, Savings, IRA, etc.)
Telephone Number
Key Creditor / Vendor
Contact Name (if any)
Account Type (Credit Card, Accounts Payable, Open Line, etc.)
Telephone Number
Key Creditor / Vendor
Contact Name (if any)
Account Type (Credit Card, Accounts Payable, Open Line, etc.)
Telephone Number
14. AMOUNT OF ESTIMATED LOSS:
(if unknown, enter a question mark)
☐ Real Estate: ☐ Leasehold Improvements:
☐ Machinery and Equipment: ☐ Loss of Sales:
☐ Inventory: ☐ Other:
15. INSURANCE COVERAGE (IF ANY)
Coverage Type: ☐ Property Insurance
☐ Bus
iness Interruption Insurance
☐
Other
Name of Insurance Company and Agent:
Phone Number of Insurance Agent:
Policy Number:
16. Describe the type and extent of physical damage and/or economic injury that your business has experienced as a
result of the declared disaster. Attach photographs or other evidence of the physical damage.
17
. OWNERS: (must include all the following information)
Application must include the following information for the individual(s) who, individually or collectively, own at
least fifty-one percent (51%) of the equity of the business, as evidenced by the businesses tax statements.
(A) OWNER APPLICANT 1:
(if less than 51% owner, additional owner applicant(s) are needed)
Full
Legal
Name
Title/Office
% Owned*
E-mail Address
6 P a g e 20200323 COVID-19
Social Security Number
Date of Birth
Driver’s License Number
Telephone Number (area
code)
US Citizen
☐
Yes
☐No
Mailing Address
City
State
Zip
(B) OWNER APPLICANT 2:
(if applicant 1 is less than 51% owner)
Full
Legal
Name
Title/Office
% Owned*
E-mail Address
Social Security Number
Date of Birth
Driver’s License Number
Telephone Number (area
code)
US Citizen
☐
Yes
☐No
Mailing Address
City
State
Zip
(C) OWNER APPLICANT 3:
(if applicants 1 and 2 are less than 51% owner)
Full
Legal
Name
Title/Office
% Owned*
E-mail Address
Social Security Number
Date of Birth
Driver’s License Number
Telephone Number (area
code)
US Citizen
☐
Yes
☐No
Mailing Address
City
State
Zip
(D) OWNER APPLICANT 4:
(if applicants 1 - 3 are less than 51% owner)
Full
Legal
Name
Title/Office
% Owned*
E-mail Address
Social Security Number
Date of Birth
Driver’s License Number
Telephone Number (area
code)
US Citizen
☐
Yes
☐
No
Mailing Address
City
State
Zip
*
Total of all owners listed must be equal to or greater than 51% of total business ownership. Attach additional sheet if needed.
18. IF DIFFERENT THAN 17(A) and 17(B) ABOVE, PROVIDE THE NAME(S) OF THE INDIVIDUAL(S) TO CONTACT FOR
INFORMATION NECESSARY TO PROCESS THIS APPLICATION:
Name (Primary)
Name (Alternative)
Telephone Number
Telephone Number
Email
Email
7 P a g e 20200323 COVID-19
19.
If anyone assisted you in completing this application, whether you pay a fee for this service or not, that person must
print and sign their name in the space below.
Name and Address of Representative (please include the individual name and their company)
S
ignature of Individual Print Individual Name
Name o
f Company Phone Number (include Area Code)
Str
eet Address City, State, Zip
Unless the NO box is checked, I give permission to discuss any portion of this application with the representative listed abo
ve. NO ☐
SECTION V. BORROWER CERTIFICATION AND
ACKNOWLEDGMENT
I/We understand that the State of Florida Small Business Emergency Bridge Loan Program is designed to provide a short-term
loan to “bridge the gap” between the time a major catastrophe occurs and when a business has secured other capital
resources. I/We understand that I/we are responsible for repayment of any funds loaned under the Program.
I/We intend to repay the loan through one or more of the following sources:
☐ I/We have applied or intend to apply for a U.S. Small Business Administration (SBA) Disaster Loan, SBA Disaster
Loan(s) or other Federal Assistance.
☐ I/We have applied or intend to apply for a loan from my banking institution.
☐ I/We have filed a claim with our insurance company for damages.
☐ I/We will have other resources available to repay the loan.
APPLICANT(S) SIGNATURE(S)
APPLICANT 1 (16A)
APPLICANT 2 (16B)
Print Name
Print Name
Signature
Signature
Date
Date
APPLICANT 3 (16C)
APPLICANT 4 (16D)
Print Name
Print Name
Signature
Signature
Date
Date
[END OF APPLICATION]
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COVID-19 Florida Emergency Bridge Loan Application - April 2020

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Completed 3 April 2020

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