Appendix C: Local Business Worksheet
Matc
h on Main COVID-19 Response Program
Local Business Worksheet
City of Adrian
Local Business Worksheet
Point of
Contact
First and Last Name:
Email:
Cell Number:
Office Number:
Best way to contact you:
Email
Cell Phone
Business Role:
Owner
Employee
describe your role
Business
Information
Business Name:
Street Address:
City:
State:
Zip Code:
Business Type:
Retail
Restaurant
Service
Other
Is your business a for-profit entity?
Yes
No
Is your business headquartered in Michigan?
Yes
No
Does your business have 25 or less employees?
Yes
No
How many jobs are going to be retained by your businesses (full and part time)?
Business
Location
Is your business a brick-and-mortar storefront with
face to face operations located within the City of
Adrian Downtown Development Authority?
Local District Map:
https://adriancity.com/wp-
content/uploads/DDA-
Boundary-map.pdf
Yes
No
Low to
Moderate
Income
Why are we asking? Through the Michigan Economic Development Corporation
(MEDC)’s Match on Main-COVID-19 Response Program, preference will be given to
applications that include businesses with owners who financially qualify as low-to-
moderate income based on federally supplied data.
If a business owner does not qualify as low-to-moderate income, applicants may still
include the business in their application. The low-to-moderate income qualification is
only a preference of the program. A business owner failing to meet the low-to-
moderate income threshold for their County does not disqualify the business from
inclusion in the application.
Extremely Low Income Limits ($)
Family Size
1 2 3 4 5 6 7 8
14,750 17,240 21,720 26,200 30,680 35,160 39,640 44,120
As a business owner, I qualify as low-to-moderate income based on the data above.
As a business owner, I do not qualify as low-to-moderate income.
COVID-19
Related
Impacts
COVID-19
Related
Impacts
(Continued)
Has your business realized a significant financial
hardship related to COVID-19?
Yes
No
Please describe the impacts COVID-19 has had on your business below.
Family Size
1 2 3 4 5 6 7 8
24,550 28,050 31,550 35,050 37,900 40,700 43,500 46,300
Low (80%) Income Limits ($)
Family Size
1 2 3 4 5 6 7 8
39,300 44,900 50,500 56,100 60,600 65,100 69,600 74,100
Very Low (50%) Income Limits ($)
If your business received funding support from the MEDC’s Match On Main COVID-19
Response Program, how would you use the funds?
Previous
MEDC
Grants or
Loans
Have you received financial support from any of the following Michigan Economic
programs?
Michigan Small Business Relief Program: The
Michigan Small Business Relief Program created by the
MSF includes grants and loans administered in
conjunction with the regional economic development
organizations (EDOs). More information here:
here:https://www.michiganbusiness.org/about-
medc/covid19/small-business-relief-program/
Yes
No
Unsure
Match on Main Program: Match on Main is a grant
program for small businesses located in Select or
Master Level Michigan Main Street Communities.
More information here:
https://www.miplace.org/small-business/resources/
Yes
No
Unsure
Local
Questions &
Considerations
In order to help identify which businesses receive funding locally, the City of Adrian
would also like small business applicants to answer the following questions.
Question 1: Has your business been in operation for at least two years?
Question 2: Is your business open to the public on a regular basis?
Question 3: Was your business delinquent on any accounts, fees and tax
assessments prior to the City’s emergency order related to the COVID-19 pandemic?
**Upon completion, please submit to:
Greg Elliott, AICP, Community Development Director
City of Adrian
gelliott@adrianmi.gov
Have questions or need assistance? Please contact:
Greg Elliott, AICP Community Development Director, at (517) 264-4857 or gelliott@adrianmi.gov
Chris Miller, Economic Development Coordinator at (517) 902-6100 or cmiller@adrianmi.gov
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