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.
Authorized Representative Signature
Due to the COVID-19 State of Emergency, completed application forms and all attachments should be scanned and
emailed to firstname.lastname@example.org or can be mailed to:
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 email@example.com.
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.
click to sign
click to edit