Fillable FCRG Eligibility Qualification Application

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FCRG Eligibility Qualification Application

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Fairfax City ReConnected Grant Program Application
Round 1 - Eligibility Qualification
Overview:
During the qualification round (Round 1) of the Fairfax City ReConnected Grant (FCRG)
program, applicants will be required to provide the Economic Development Authority (EDA)
with the necessary information to confirm program eligibility. The EDA will verify this
information and invite eligible applicants to the Round 2 of applications via email by July 13
th
.
Information gathered during Round 1 and through permission granted by the applicant to the
Commissioner of the Revenue will be used to create a data model that measures eligible
applicants based on their relative need as a result of COVID-19. This formula will be used to
determine the percentage of grants allotted to each business category during the Round 2 of
applications (open July 15 – 22). Small, Women-Owned, Minority-Owned (SWaM) and
Veteran-Owned business will receive at least 30% of the total allotment of all ReConnected
grants ($5,000 & $10,000) regardless of business category.
At the end of this application, applicants are asked to pick which amount best suits their needs,
either $5,000 or $10,000. This will aid the FCRG staff in the planning of future fund allocations.
During Round 2 of the application (open July 15 – 22), businesses requesting $10,000 will be
required to provide additional information, which may include a narrative, detailing their previous
and proposed response to COVID-19 and why their need is above and beyond that required of the
$5,000 level program.
Round 1 applications with all accompanying documentation are due on July 8
th
at 5 pm to
ReConnectedGrant@fairfaxcityeda.org.
If you have any questions, please reach out to ReConnectedGrant@fairfaxcityeda.org.
*All questions are required unless otherwise stated.
* Given the limited nature of funding, the EDA does not guarantee the award of any funds to any
applicant. Filling out the following application does not guarantee funding.
*Please fill in answers to the best of your knowledge. All answers submitted by the applicants
are subject to inspection by the FCRG staff and the Fairfax City Commissioner of the Revenue.
*All businesses applying to the FCRG must complete the Taxpayer Information Confidentiality
Waiver at the end of this application.
Section 1 - Business Information:
Business Name: _______________________________________________________________
Local Business Address: ________________________________________________________
_____________________________________________________________________________
_____________________________________________________________________________
Does your business have multiple locations? _______ Yes ________ No
If yes, provide addresses below: _____________________________________________
______________________________________________________________________________
______________________________________________________________________________
Business Website: ______________________________________________________________
Fairfax City Business, Professional and Occupancy License (BPOL) number: _______________
Does your businesses occupy leased space? _______ Yes ________ No
If yes, on what date does the current lease expire? ______________________
Is the business owner registered with the Commonwealth of Virginia as a Small, Woman-
Owned, and Minority-Owned (SWaM) business? _______ Yes ________ No
If yes, please provide certification number: _____________________________________
If the business is not registered with the State of Virginia as a SWaM business, it may still fall
within one of the following categories. By clicking “yes” you are indicating that 51% of
ownership is held by one of the below distinctions:
Women-Owned: ________ Yes
Minority-Owned: ________ Yes
Veteran-Owned: ________ Yes
Business Type:
Please select all that apply. If other, please provide a description in the space provided.
___ Sole Proprietorship ___ Partnership
___ Corporation ___ LLC
___ Non-Profit ___ Co-op
___ Franchise ___ Owner-Operated
___ Independent ___ Other: _________________
Business Category:
Please select all that apply. If other, please provide a description in the space provided.
___ Arts, Entertainment, Recreation
___ Child Care, Education, Instruction
___ Construction, Engineering, Design Services
___ Distribution, Logistics, Warehousing
___ Finance, Insurance, Real Estate
___ Government, including political divisions of the Commonwealth
___ Health and Medical Services
___ Hotel and Accommodations
___ Information Technology, Broadcasting, Publishing
___ Manufacturing
___ Personal Services (barber shop, nail salon, fitness, dry cleaner, etc.)
___ Private Household Services
___ Professional, Technical, Business Services
___ Repair and Maintenance Services
___ Restaurant, Food Services
___ Retail – please specify _____________________
___ Social Services
___ Transportation
___ Other: ______________________________________________________________
Section 2 - Business Owner information:
Is the person submitting the application the business owner? _______ Yes ________ No
Business Owner(s) Name(s): ______________________________________________________
Business Owner Phone Number: ___________________________________________________
Business Owner Email Address: ___________________________________________________
Contact information for the person submitting the application if not owner: _________________
______________________________________________________________________________
Title of person submitting the application if not owner: _________________________________
Section 3 - Eligibility:
On what date did the business begin operating in the City of Fairfax? _____________________
Is the business a for-profit entity of a non-profit? _______ Yes ________ No
Is the business current on all tax payments to the City of Fairfax? _______ Yes ________ No
Does the business intend to continue operations at a location within the City of Fairfax until
December 30, 2020? _______ Yes ________ No
How many full time and full time-equivalent employees did the business employ across all
locations as of March 1, 2020? ____________________________________________________
Is the business currently in bankruptcy proceedings? _______ Yes ________ No
Revenue Information:
Please provide a summary of the Gross receipts (revenue/sales before any expenses) for the
months indicated. Supporting documentation is required and more information is below.*
2019
2020
March
$
$
April
$
$
May
$
$
*Supporting Documentation:
• All businesses:
o Detailed Profit and Loss statement for March, April, and May 2019 AND
2020. If a detailed Profit and Loss statement cannot be provided, please
submit detailed bank statements for the period referenced.
• Restaurants:
o P&L statement and a detailed summary of meal taxes paid for the period
referenced.
• Retail
o P&L statement and a detailed summary of sales tax paid for the period
reference.
Please provide the following Business, Professional and Occupational License information for
confirmation by the Commissioner of the Revenue.
2019 BPOL Annual Gross Receipts (Due March 1, 2020): _________________________
Section 4 - Additional Information:
Answers to these questions are not required and will not be considered for determination of
eligibility.
Did your business close temporarily as a result of COVID-19 between March 2020 and June
2020?
_______ Yes ________ No
Has the business applied for federal small business relief through the Economic Injury Disaster
Loan (EIDL) Program? _______ Yes ________ No
Was the business’s application to the federal EIDL Program approved?
_______ Yes ________ No
Has the business applied for federal small business relief through the Paycheck Protection
Program (PPP)? _______ Yes ________ No
Was the business’s application to the federal PPP approved?
_______ Yes ________ No
Would you like to receive updates from the EDO? _______ Yes ________ No
Are you planning on applying for one of the fifty $10,000 ReConnected Grants?
During Round 2 of the application (open July 15 – 22), businesses requesting $10,000
will be required to provide additional information, which may include a narrative,
detailing their previous and proposed response to COVID-19 and why their need is
above and beyond that required of the $5,000 level program.
_______ Yes ________ No
Would your business like to take the Fairfax City ReConnected Pledge?
If yes, please read and agree to the information below.
_______ Yes ________ No
The Fairfax City ReConnected Pledge identifies businesses that are implementing safety
precautions and best practices concerning COVID-19. Businesses taking the pledge commit
to:
• requiring the use of face coverings by employees and customers;
• communicating safety protocols and training to managers and staff;
• working only when healthy;
• promoting social distancing and limiting capacity;
• cleaning and disinfecting frequently;
• adhering to specific business sector health and safety requirements by the Virginia Health
Department.
By agreeing to take the Fairfax City ReConnected Pledge, your business is communicating that
you have read and agree to the Fairfax City ReConnected Pledge as stated above. This is not a
guarantee, or indication that this business has a COVID-19 Preparedness Plan, or requires one.
The City is not responsible for enforcement of any COVID-19 preparedness efforts by
businesses.
_______ I have read and agree to the Fairfax City ReConnected Pledge
Taxpayer Information Confidentiality Waiver
Pursuant to § 58.1-3, of the Code of Virginia, certain information regarding taxpayers is
protected as confidential under Virginia law (“Confidential Taxpayer Information”).
As part of the requirements of the City of Fairfax (the “City”) Reconnected Grant Program
(the “Grant Program”), _________________________________________ (the “Business”)
hereby consents to and authorizes the limited dissemination of certain Confidential Taxpayer
Information regarding the Business, as described herein, to certain City departments and
employees. In particular, the Business hereby consents to the disclosure of all of the following
information described below (the “Disclosed Information”) held by the City of Fairfax
Commissioner of Revenue to the City of Economic Development Office and to any City
employees charged with administration of the Grant Program:
1. All information relating the name, address, business license tax classification, and
ownership of the Business;
2. All information relating to the gross receipts, revenue and property of the business; and
3. All information relating to the tax filing, assessment and payment history of the Business,
including any late payment or filing penalties, statutory assessments, audit finding, liens
or judgments.
The Disclosed Information shall include all information described above relating to the
Business for the current and all preceding tax years, as well as for any tax years for which the
Business applies or qualifies for the Reconnected Grant Program.
By signature of the undersigned authorized representative, the Business hereby consents to
the disclosure of the Disclosed Information. The person signing this form affirms that he or she is
authorized to waive tax confidentiality for, and is acting with the explicit authorization of, the
Business.
_______________________________________________
(INSERT NAME OF BUSINESS)
_______________________________________________
(STREET ADDRESS)
FAIRFAX, VA
Name of Representative: ____________________________ Title: _______________________
City/County of _________________________, Commonwealth of Virginia, to wit:
I, ______________________________________, do certify that I am the legal representative or
agent of __________________________________________ and authorized to act in an official
capacity on its behalf.
____________________________________________ _________________________
(SIGNATURE OF REPRESENTATIVE) Date
Email Address: _________________________________________________________________
Telephone Number: _____________________________________________________________
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FCRG Eligibility Qualification Application

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Completed 16 July 2020

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