Fill - Free fillable SB PRL Application PDF (City of Green Bay) PDF form

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

CITY OF GREEN BAY

SMALL BUSINESS PANDEMIC RELIEF LOAN APPLICATION (SB-PRL)

BUSINESS INFORMATION

Name of Business:

Dba Name (if applicable):

Mailing Address:

City: State: ZIP Code:

Phone:

Email:

Address of Operations (if different):

City: State: ZIP Code:

Date of Incorporation:

Current Number of FTE Employees at Time of Appli-

cation:

Is Business Minority-Owned? Yes No

Has the business ever been subjected to criminal or civil fines and penalties including from City

of Green Bay code or regulatory violations?

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

Business Type: LLC Partnership Sole Proprietor Other

BUSINESS DESCRIPTION

OWNER INFORMATION

OWNER NAME(S) (please indicate percent of ownership if multiple owners):

Mailing Address:

City: State: ZIP Code:

Phone: Email:

18 or older:

Yes No

(circle)

Please summarize owner’s experience in industry (

PLEASE LIST ADDITIONAL OWNER INFORMATION BELOW OR

ATTACH SERPARATE PAGE IF NECESSARY)

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

PROPOSED USES OF FUNDS

AMOUNT OF REQUEST

USE

Payroll expenses

Rent/mortgage

Utilities

Other:

Total Emergency Funding Request (Max $5,000 FOR EMPLOYERS WITH FEWER THAN 20 FTE EMPLOYEES and Max

$10,000 FOR EMPLOYERS WITH 20 to 100 FTE EMPLOYEES):

EMERGENCY NEED

Please specify below how your business will be impacted by the policies put into effect due to

the current coronavirus pandemic OR will provide a support service and need funding assis-

tance to implement new protocols or meet higher demand:

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

Please specify below how many Full-Time Equivalent jobs your business intends to retain or

create through the funds provided by the Emergency Fund. NOTE: jobs retained must be held throughout the

term of the forgivable loan, otherwise the loan will be called due and payable. At least 51% of FTE jobs retained must be held by mem-

bers of low-/moderate-income households.

Position Title:

eld by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Position Title:

Held by Low-/Mod-

Income?

Yes No

Hours Worked per Week:

Please indicate any additional jobs retained on a separate sheet

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

APPLICANT STATEMENT: I hereby certify that the information on this form is complete and accurate. I under-

stand that the information provided may be subject to further verification by the City of Green Bay, or the US De-

partment of Housing and Urban Development. If necessary, I will provide the information required to verify this data

(e.g. payroll records, tax fillings, bank account statements, etc.). I, therefore, authorize such verification, and I will

provide the supporting documentation, if necessary.

SIGNATURE: ______________________________________________Date: _______________________

Name (please print):________________________________________________________________________

Title (please print):_________________________________________________________________________

SIGNATURE: ___________________________________________________Date: ________________________

Name (please print):________________________________________________________________________

Title (please print):_________________________________________________________________________

SIGNATURE: ____________________________________________________Date: _______________________

Name (please print):________________________________________________________________________

Title (please print):_________________________________________________________________________

Please provide signature(s), printed name(s), and title(s) of additional owners on separate page (if applicable).

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

Please submit copies of documents if available/applicable

SB-PRL Fund Application (this document)

Owner Income self-verification form using template in Appendix A

Owner’s most recently completed IRS Form 1040

Employee Income self-verification forms using template in Appendix A (Submit one

for each employee proposed to be retained)

Business Operating Agreement – (for businesses with multiple partners)

Payroll summary or other document showing total number of employees on pay-

roll as of the application submission date

Section 3 registration (if applicable)

NOTE- Staff may follow-up with applicants for additional information and documents after

application submission as necessary.

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

APPENDIX A

APPLICANT INCOME ELIGIBILITY – to be completed and signed by each employee whose position is proposed to

be retained. At least 51% of FTE jobs to be retained must be low-/moderate-income for their household size. The

business owner is also required to complete this form and provide City staff with the most recently submitted IRS

Form 1040, even if no jobs are proposed to be retained or created through Emergency Fund assistance.

Information on annual family income and race is required to determine eligibility for services funded with federal Community Devel-

opment Block Grant (CDBG) funds. Each participant must indicate the number of person in their household and then CIRCLE

THE BOX that contains the amount of annual family income.

INCOME

is defined as the annual gross income (before deductions) of all family and non-family members 18+ years old living in the

household. All sources of income must be counted from all persons in the household based on the anticipated income expected in

the next 12 months.

Please circle your Income Range based on your Family Size (for example: if there are 5 people in your household go

to HH of 5; if there are 8 or more go to HH of 8):

HH of 1

HH of 2

HH of 3

HH of 4

HH of 5

HH of 6

HH of 7

HH of 8

Low-

/Moder-

ate-In-

come

$0-

$17,300

$0-

$19,800

$0-

$22,250

$0-

$26,200

$0-

$30,680

$0-

$35,160

$0-

$39,640

$0-

$44,120

$17,301-

$28,850

$19,801-

$32,950

$22,251-

$37,050

$26,200-

$41,150

$30,681-

$44,450

$35,161-

$47,750

$39,641-

$51,050

$44,121-

$54,350

$28,851-

$46,100

$32,951-

$52,700

$37,051-

$59,300

$41,151-

$65,850

$44,451-

$71,150

$47,751-

$76,400

$51,051-

$81,700

$54,351-

$86,950

Non-Low

Income

$46,101+ $52,701+ $59,301+ $65,851+ $71,151+ $76,401+ $81,701+ $86,951+

Please check your ethnicity (pick 1 of 2): □ Hispanic/Latino □ Non-Hispanic/Latino

Please check your race (pick 1 of 10 choices):

□

White

□

Black or African American

□

Asian

□

American Indian/Alaskan Native

□

Asian & White

□

American Indian/Alaskan Native & White

□

Native Hawaii/Other Pacific Islander

□

Black/African American & White

□

American Indian/Alaskan Native & Black/African American

□

Other Multi-Racial

Does your family have a FEMALE HEAD OF HOUSEHOLD? □Yes □No

APPLICANT STATEMENT: I hereby certify that the information on this form is complete and accurate. I understand that this

self-certification may be subject to further verification by the agency providing services, the City of Green Bay, or the US Depart-

ment of Housing and Urban Development. If necessary, I will provide the information required to verify this data (e.g. pay stubs,

bank account statements, etc.). I, therefore, authorize such verification, and I will provide the supporting documentation, if neces-

sary. WARNING: Title 18, Section 1001 of the US Code states that a person is guilty of a felony for knowingly and willingly mak-

ing false or fraudulent statements to any department of the US Government.

Name: _______________________________________________(printed)

Signature: _______________________________________________Date: ___________________

Page | 8

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

APPENDIX B

SMALL BUSINESS PANDEMIC RESONSE PROGRAM

SCORING MATRIX

If the purposed project meets all threshold criteria, reviewers will utilize the following project scoring criteria to evaluate the pur-

posed project for the purposes of making a funding recommendation. Scoring will help determine priority of project application

versus other projects competing for funds. The highest scoring projects will be recommended for funding.

Evaluation Criteria (100 Point Scale + Bonus):

Capacity and Experience to Operate the Business (15 Points)

o Applicant has the demonstrated capacity to operate the business sustainably. Con-

sider project status, industry experience, and business development classes and

resources.

Readiness to Proceed (10 points)

o The Business a proof of concept and clear market analysis. Proposal includes a

clear plan for implementation including a realistic timeline with set deliverables.

Business Impact (15 Points)

o Business will be severely impacted by the policies put into effect due to the coro-

navirus pandemic OR business provides a support service and will need funding

assistance to implement new protocols or meet higher demand. This qualification

meets the DCED ESF-14 goals.

Job / Employee retention (30 Points max)

o Proposal ensures employee retention for term of loan. Up to 30 Pts awarded

based on Full-Time Equivalent FTE job retention: 30 Pts for 5 or more FTE posi-

tions retained, 20 Pts for 3 or more FTE retained, 10 points for 2 FTE positions

retained, 5 points for 1 FTE positions retained, and 0 points for a lower ratio of

retained jobs. One FTE position is defined as 40 hrs per week, or any combina-

tion of part-time positions combining for 40 hours per week, including owners.

Minority Business Enterprise (10 points)

o Business is a minority-owned business: Women, Veteran and Economically Disad-

vantaged Small Business Enterprise (51%).

Section 3 Registered (10 points)

o Business is a HUD-registered Section 3 business enterprise.

https://portalapps.hud.gov/Sec3BusReg/BRegistry/RegisterBusiness

Located in a Retail District (10 points)

o Business is or will be located in an established business corridor.

Application Completeness (5 Point BONUS)

o Up to 5 point bonus for application with concise descriptions and backup infor-

mation, professional writing and accurate math.

TOTAL

Page | 9

City of Green Bay - Small Business Pandemic Relief Loan APPLICATION

-Helpful links-

City of Green Bay - Department of Community and Economic Development

https://www.greenbaywi.gov/business

Federal EIN –

https://www.irs.gov/businesses/small-businesses-self-employed/apply-for-an-employer-identification-number-

ein-online

WI Business Resources- registration and basic information

https://openforbusiness.wi.gov/

WI Dept of Financial Institutions-

https://www.wdfi.org/corporations/

WI Dept of Revenue-

https://www.revenue.wi.gov/Pages/Businesses/New-Business-home.aspx

https://www.reve-

nue.wi.gov/Pages/Form/with-home.aspx

WI Dept of Workforce Development-

https://dwd.wisconsin.gov/ui/

https://dwd.wisconsin.gov/wc/

Dun & Bradstreet- DUNS –

https://www.dnb.com/duns-number/get-a-duns.html

CAGE code-

https://www.sam.gov/SAM/

HUD Section 3 Registration-

https://portalapps.hud.gov/Sec3BusReg/BRegistry/What

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