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MicroE Certification Form revised June 2020
COVID-19 Microenterprise Stabilization Program (MicroE)
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/town taxes.
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 Rhode Island Division of Taxation 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 Town of Bristol and the R.I. Office of Housing and Community Development (OHCD) the right to
independently verify any or all of the information herein, and understand that the Town of Bristol and OHCD
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 OHCD, CommerceRI, the U.S. Small Business Administration (SBA), and the Local
Initiatives Support Corporation (LISC).
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 OHCD.
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 State of Rhode Island or
the Town of Bristol where this application is filed.
11. I certify that I will not use any MicroE grant monies to repay Economic Injury Disaster Loans (EIDL) or the Paycheck
Protection Program (PPP). I certify that the adverse financial impacts of COVID-19 on my business exceed any
assistance I have received plus any pending requests for assistance, including EIDL and PPP, by at least $5,000.
12. I certify that I am __ I am not __ a full-time student.
13. I certify that I received the attached Public Record Notification.
Signature: Date:
Printed Name: Title:
Form #4 For internal use
Date Rec’d ___/___/_____
Applicant/Business:
_______________________
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