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Clarke County CARES Act Emergency Grant Program
Program Description
Clarke County will be awarding grants to eligible, locally-based 501(c)(3) and
501(c)(19) non-profit organizations that have been negatively impacted by
the COVID-19 pandemic.
Qualification Criteria
Must be located within the limits of Clarke County, Virginia
Must be able to demonstrate a loss in revenue attributed to the COVID-19 pandemic either
by an interruption of operations, fundraising, or have COVID-19 related expenditures
Must provide all documentation requested, including details of the proposed use of grant
funds. Qualifying expenditures include payments of rent, mortgage, payroll, utilities, and
other operational expenses deemed applicable under the CARES Act program relating to
Applications can be found on the County website at (www.ClarkeCounty.gov) Applicants should
mail their completed applications to:
Clarke County Government Center
c/o Tiffany Kemp
101 Chalmers Court
Berryville, VA 22611
If you choose to drop off your application, drop it in the Treasurer’s Office drop box located in the
drive through behind the Government Center. Mark the outside of the envelope with “CARES Act
program” and mark attention to Tiffany Kemp. The deadline to submit your completed application
and materials is November 13, 2020 at 5:00 pm.
Required Information
Completed and signed application form
A projection of cash flow for the next 6- to 12-months
A copy of your 501 status with the IRS
Most recent federal tax return
Copy of driver’s license or other form of ID
Copies of the bills for which you are seeking reimbursement. For rent, include a copy of your lease
A W9 for tax purposes; see last page of this document
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1. Applicant name and title:_________________________________________________________
2. Grant amount requested: ________________________________________________________
3. Mailing address: _______________________________________________________________
4. E-mail address: _________________________________________________________________
5. Phone number: ________________________________________________________________
6. Name of non-profit _____________________________________________________________
7. Non-profit address: _____________________________________________________________
8. EIN number: ___________________________________________________________________
9. Is the non-profit located in Clarke County: Y N
10. Date of the non-profit opening in Clarke County: ______________________________________
11. Non-profit description (services provided): ___________________________________________
12. Describe how COVID-19 has impacted your operations, fundraising, and expenses:
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13. Have you applied for any additional aid during this time? If so, explain if the funds have been
accepted, denied or are pendingand for how much.
14. Financial Analysis Table: Please enter the 12-month revenue, and expenses for fiscal years ending
in 2018 and 2019.
Financial Statement
Calendar Year 2018
Calendar Year 2019
Total Revenue
Total Expenses
Enter 1-month revenue and expenses totals for January to June of 2020.
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Grant funds must be used to reimburse the costs of operation interruption caused by required closure
and/or costs related to reopening. Acceptable uses of grant funds include:
Personal Protective Equipment (PPE)
Payroll Expenses for employees whose work duties are substantially dedicated to
mitigating or responding to the COVID-19 public health emergency.
o Note: If you received EIDL or PPP funds, this grant may not be used for the same
Other equipment and supplies to promote health and safety
Technology to facilitate business operations
Professional services related to the design and construction/alteration of the building
environment necessary to promote physical and social distancing, as well as the actual
costs of the alterations
Initial cleaning and disinfection services prior to reopening
Rent or mortgage costs
Utilities (gas, electric, communication)
Please provide a line item list including dollar amount of how you will use the grant if awarded.
Example: May rent
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I certify that the information I am providing is true and accurate to the best of my knowledge. I
authorize Clarke County to make inquiries as necessary to verify the accuracy of the statements made
by me. I understand that false statements will result in forfeiture of benefits. I understand this
application, even if favorably received, does not constitute a commitment on the part of Clarke County
to extend grants. I understand that by submitting this application, Clarke County is under no obligation
to approve and/or extend an assistance grant. I agree to indemnify and hold harmless Clarke County,
its officers, directors, employees, agents and volunteers from any and all claims, loss or other liability
arising from or related to the services that Clarke County provides before, during, and after the grant
review process (including reasonable attorney fees). I agree to be bound by the grant agreement, if my
application is accepted. I agree to provide documentation, if needed, of all uses of grant funding.
Notice: Clarke County is dedicated to maintaining the confidentiality of all private client information
including proprietary business data, business plans, and tax ID numbers. As an organization receiving
financial support from state and federal agencies, we may be required to document and share client
information with public and non-profit agencies as a condition of program funding.
Clarke County will make available to the public, through FOIA, the names of any non-profits receiving
these public funds.
NOTE: The IRS does consider monies through this grant program taxable income. Therefore, the
appropriate tax forms will be issued.
By checking this box, I certify that I am not using this grant money for the same expenses and
same time periods as EIDL, PPP, or other grant awards.
Signature of Executive Director or Board Chair
Print Name of Executive Director or Board Chair
____ A completed and signed application form
____ A copy of your IRS 501 status
____ A copy of your most recent federal tax return
____ A copy of your driver’s license or other form of ID
____ Copies of bills for which you are seeking reimbursement. For rent, include a copy of your lease
____ A W9 for tax purposes; see last page of this document.
Questions? Please contact Tiffany Kemp at tkemp@clarkecounty.gov or 540-955-5100
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