First Name:
Last Name:
Business Name:
Business Address:
City State Zip Code
Phone Number(s): Cell:
E-Mail Address:
Business Or
ganization Type: Sole Proprietor Limited Liability Company
Corporation Partnership
Company Name % Interest Owned Title
Please provi
de a brief narrative of the impact COVID-19 has had on your business:
Use of Funds: Please describe how the COVID-19 Emergency Loan will be used to help your small business
retain/hire employees and keep your business operating during this challenging time?
Use: $:
Use: $:
Use: $:
Use: $:
Use: $:
Total $:
Have you applied or do you plan on applying for any other COVID-19 financial assistance programs (SBA
Disaster Loan, Payroll Protection Loan, etc.)? If so, list assistance applied for, and note if it was received:
Years in Business: Years at Present Address:
Lease Expiration Date: Monthly Rent:
Type of Business:
Average Gross Annual Receipts: $
Please indicate the square footage of the occupied space:
Amount of Personal Funds Invested in the Business to Date: $
Loan Amount Requested: $
Number of Employees Before COVID-19 Full-Tim e:
Jobs Expected to be Retained/Hired as a Result of this Loan Full-Time:
$ 0.00
Please describe your plans and ability to persevere to the best of your ability through the COVID-19 State of
Please describe the economic and/or community benefits your business creates for the City of Massillon:
Please continue to next page.
Required Application submittals and Eligibility Certifications
By checking each box below, the undersigned herby certifies that the statement is true and/or that the required
submittals are provided in conjunction with the application.
I confirm that my business is located within the City of Massillon and the business maintains all proper
licenses and permits for operation.
I certify that my revenue has declined by 30% or more as a result of COVID-19 since March 9, 2020. Attach
balance sheet, profit loss statement or other financial documentation that demonstrates the required
decline in revenue.
I certify that the average annual gross receipts of the business is less than $2,000,000
I have attached a completed IRS W-9 Form and DUNS number.
I have provided documentation to help verify the economic hardship suffered as a result of COVID-19,
including financial statements, and other data as applicable.
I agree to document and report the economic impact to the business as a result of this loan, including but not
limited to, jobs retained, job hired, increased sales, participation in other relief programs.
I confirm that the business is current with all local, state, and federal taxes.
I certify that the business has complied with its bylaws or other governing documents to obtain approval
for the undersigned to submit this application and execute a loan agreement on behalf of the applicant.
I certify that the above information, to the best of my knowledge is accurate and true. I understand that
the CITY will rely on the accuracy of the submittal and certifications made in conjunction with this application.
Any misrepresentation or inaccurate information may be treated as a default concerning any loan made.
Business Name
Authorized Representative Signature
Due to the COVID-19 State of Emergency, completed application forms and all attachments should be scanned and
emailed to or can be mailed to:
Samantha Walters
Community Development Director
City of Massillon
151 Lincoln Way East
Massillon, OH 44646
If you have questions about the application requirements or have any issues with submitting any of the required
documents, please email
The City of Massillon does not discriminate in its programs and activities on the basis of age, color, gender expression/
identity, genetic information, marital status, national origin, physical or mental disability, pregnancy, race, religion,
sex, sexual orientation, or veteran status, as applicable.
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