Fillable COVID-19 Microenterprise Stabilization Program (MicroE) Application (Town of Bristol)

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COVID-19 Microenterprise Stabilization Program (MicroE) Application (Town of Bristol)

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The COVID-19 Microenterprise Stabilization Program (MicroE) Application (Town of Bristol) form is 7 pages long and contains:

  • 1 signature
  • 84 check-boxes
  • 50 other fields

Country of origin: US
File type: PDF

U.S.A. forms for Town of Bristol

BROWSE TOWN OF BRISTOL (RI) FORMS

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Page 1 of 7
MicroE Application
COVID-19 Microenterprise Stabilization Program
(MicroE) Application
By completing this application form, I acknowledge that I have been notified that MicroE
Program funds are available on a first come, first serve basis. A tentative approval is not a
guarantee of funding. This is a federally funded Community Development Block Grant (CDBG)
program, and program eligibility requirements must be met to receive a grant.
The MicroE Eligibility Information Sheet was provided to me. I have reviewed the information
provided and own an eligible microenterprise. I understand that I, and any co-owners, must
income qualify to receive a grant. I understand this application will only be reviewed after all
required certifications and forms have been completed, and all required supporting
documentation has been provided.
(See MicroE Checklist)
Please provide the following information about your business:
1) Applicant Contact Information
a. Last Name
b. First Name
c. Work Phone Number
d. Cell Phone Number
e. Email
2) Business Name
a. Legal Name
b. Doing Business As (DBA)
Form #1 For internal use
Date Rec’d ___/___/_____
Applicant/Business:
_______________________
Page 2 of 7
MicroE Application
3) Business Information
a. Business Sector
b. Business Description
c. Business website or social media page?
d. Do any of the following describe your business? (Check all that apply.)
___ cannabis-related business
___ real estate rentals/sales
___ home-based business with no employees
___ business owned by persons under age 18
___ franchise
___ chain
___ business opened after 1/1/2020
___ liquor store
___ independent consultant/contractor providing services to one entity
___ home-based business restricted to patrons below age 18
___ weapons/firearms dealer
___ lobbying firm
___ none of the above
e. Date business established:
f. NAICS Code from https://www.bls.gov/bls/naics.htm, search under Industry
Finder (six digits)
g. Legal Type
Select one
Select one
Page 3 of 7
MicroE Application
h. DUNS or EIN number? (Not required to apply. If you receive an award, you
will need to have both for federal reporting purposes.)
DUNS # EIN#
i. Is this a home-based business? Y / N
4) Applicant/Owner Information
a. Are you age 18 or older? Y / N
b. Are you a student? Y / N
c. Race:
d. Are you Hispanic/Latinx? Y / N / Prefer not to answer
e. Sex: Female / Male / Non-binary / Prefer not to answer
f. What is your disability status? Disabled / I currently do not have disability
status / Prefer not to answer
5) Business Owner Mailing Address:
a. Street or PO Box
b. City
c. State
d. Zip
e. County
6) Business Co-owner (if applicable)
a. Co-owner(s) must also meet the income eligibility requirement.
b. Co-owner’s Name
c. Co-owner’s Email
d. Is the co-owner a student? Y / N
e. Is the co-owner age 18 or older? Y / N
f. Co-owner race:
g. Are you Hispanic/Latinx? Y / N / Prefer not to answer
h. Sex: Female / Male / Non-binary / Prefer not to answer
i. What is your disability status? Disabled / I currently do not have disability
status / Prefer not to answer
Select one
Select one
Page 4 of 7
MicroE Application
7) Business Street Address:
a. Street
b. City
c. State
d. Zip
e. County
f. Property Owner
8) Funding Criteria
a. Does your business have a physical establishment located in Bristol?
Y / N
The physical establishment is at the same location or address as my, or my
co-owner’s, primary residence. Y / N
b. Are you an employee of your business? Y / N
How many employees does your business have today, including you?
#
How many employees did your business have, including you, during the pay
period ending March 7, 2020? #
Is the business registered with the R.I. Secretary of State’s office? (Only
required for certain business types.) Y / N
If yes, enter Identification No.
c. Is the business in good standing with the State of Rhode Island?
Y / N
Are you, your co-owner(s), or your business party to any litigation against the
state or Bristol? Y / N
Have all taxes due before March 1, 2020, including February 2020 sales
taxes, been paid in full? Y / N
Enter your RI business tax ID (11 digits)
Page 5 of 7
MicroE Application
Is a state license or registration required for the business to legally operate in
Rhode Island? Y / N
If yes, list license/registration type and number (e.g. Dept. of Health Food
Serv
ice license #FSV12345, Contractor Registration #12345)
If yes, is the license/registration active and/or valid? Y / N
d. Has your business experienced a loss of income ≥ $1,000 due to COVID-19?
Y / N
e. Is your family’s total gross income at/below the low- or moderate- income
amount shown below for your family size? "Moderate income"
means less
than or equal to 80% of the
Area Median Income (AMI). Y / N
FY 2020 Mod/Low Income (80%) Limit
City/Town of Residence
1
Person
2
Person
3
Person
4
Person
5
Person
6
Person
7
Person
8
Person
All other R.I. communities
48,750 55,700 62,650 69,600 75,200 80,750 86,350 91,900
Westerly, Hopkinton, New
Shoreham
50,050 57,200 64,350 71,500 77,250 82,950 88,700 94,400
Newport, Middletown, Portsmouth
54,950 62,800 70,650 78,500 84,800 91,100 97,350 103,650
9) Estimated Adverse Economic
Impact of COVID-19
a. When did your business start declining? Date:
b. Before COVID-19, how many clients did you typically serve in one week?
c. In the past week, how many clients have you served?
d. Have you had to reduce staff hours as a result of COVID-19? Y / N
e. Have you had to lay-off or terminate staff as a result of COVID-19? Y / N
f. Has your business closed temporarily? Y / N
Page 6 of 7
MicroE Application
g. List your gross revenues for 2020, 2019, and 2018 for the same period.
Adjust Period Start and End Dates as necessary. The start and end dates for
all three years must be the same (e.g. start 3/1, end 3/31).
Year
Period End
Date
Total Gross
Revenue for
Period
Comments
2020
2019
2018
h. Please provide a brief explanation
of what adverse economic effects COVID-
19 had on your business, and any changes you have made to operations:
10) If operating capital funds are awarded, how do you plan to use the funds?
Page 7 of 7
MicroE Application
11) Attachments: Did you attach copies of
____ Your driver’s license
____ MicroE Income Certification Form
____ 2018 personal federal tax return for all adults in your family filing separately
____ Your business federal tax return for 2018 (or 2019, if filed)?
____ What was the amount of gross receipts/sales less any returns/allowances?
(line 3 of Schedule C, Form 1040; line 1c of 1120, 1065)
$______________________________
____ Payroll for week ending 3/7/2020
____ Payroll for most recent pay period
____ Receipts from the impacted period, including March 2020
____ Receipts from the same period (including March) in 2019
____ Receipts from the same period (including March) in 2018
____ MicroE Conflict of Interest Disclosure
____ MicroE Certification Form
____ MicroE Consent and Release Form
12) By signing this application, I certify that all information contained in this
application 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
CDBG assistance, as applicable under the provisions of Title 18, United States
Code, Section 1001, et seq.
Form Completed by:___________________________________
Date:
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COVID-19 Microenterprise Stabilization Program (MicroE) Application (Town of Bristol)

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Completed 9 February 2021

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