Economic Injury Worksheet (Mandatory)
Include this Economic Injury Worksheet with the submission of the grant application.
Small Business or Community Organizations State of Washington Registered Name:
Number of years in
operation within North
Bend city limits:
Grant amount requested
(from $1,000 to a max. of
Estimated amount loss
due to COVID-19 and
Governor’s order:
Estimated months of
cash reserves remaining:
Number of full-time employees (must be no more
than 25):
Business/nonprofit type (e.g., LLC, 501(c)(3), etc.):
Number of full-time employees furloughed or laid off:
Business/nonprofit sector (e.g., hospitality):
Likelihood of immediate business closure (If
Washington remains at phase 1) within 60 days from
now (indicate one):
High: _____ Medium: ______ Low: _____
Number of potential jobs lost upon permanent
business closure:
Amount anticipated to be necessary for re-opening:
(itemize needs, such as masks, gloves, sanitizer,
disinfectant, plastic/acrylic barriers, or other physical
During which phase of Washington’s recovery
strategy will business/organization reopen (Phase 1,
2, 3, 4):
1: _______ 2: _______ 3: _______ 4: _______
Is business/organization continuing to pay employee
salary and/or benefits during closure? (yes/no, with
brief explanation)
Is business/organization anessential business
according to the State of Washington? (yes/no, with
brief explanation)
If business/organization has received funding from alternative sources, please list (for example, PPP, EIDL,
Working Washington grant, other cities, etc.):
Has business/organization applied for, but not been approved for, alternative grant sources? (yes/no, with
brief explanation)
Intended use of funds (for example, rent/mortgage, wages, taxes, benefits, typical operating costs, personal
protective equipment, etc.):
Brief description of applicant’s activities (for example, franchise details, business model, etc.):
Is business/organization pending legal action (for example, eviction, bankruptcy, lawsuits, etc.)? (yes/no,
with explanation):
Briefly describe the economic impact to business/organization from COVID-19 or the Governor’s Safe Start
Washington’ order:
Briefly describe the difference between the business/organization’s Q2 2019 revenue and Q2 2020 revenue:
If funded, would business/organization reopen and likely completely recover? (yes/no, with brief explanation)
Will business/organization require additional funding sources beyond this grant to reopen? (yes/no, with brief
Please describe how business/organization has participated in the North Bend community (such as
supporting local activities, clubs, teams, charities, events, etc.):