Fillable Voucher-Remittance-Declaration-FORM Voucher Remittance Declaration FORM

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Voucher-Remittance-Declaration-FORM Voucher Remittance Declaration FORM

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_________________________________ _________________________________
____________________________________________________________________________
SAVE OUR SMALL BUSINESSES GRANT PROGRAM
RECIPIENT VOUCHER REMITTANCE FORM
This form is used for the disbursement of proceeds provided by Federal Care Act funds.
APPLICATION NUMBER: ____________________________________
BUSINESS NAME: ____________________________________
TODAY’S DATE: ____________________________________
BUSINESS ADDRESS: ____________________________________
CITY, STATE, ZIP CODE: ____________________________________
CONTACT PERSON: ____________________________________
TITLE: ____________________________________
TELEPHONE: ____________________________________
EMAIL: ____________________________________
BUSINESS TYPE: ____________________________________
# OF EMPLOYEES: ____________________________________
Per Program Guidelines, businesses with 1-5 employees are eligible to receive $5,000 and businesses with 6-25
employees are eligible to receive $10,000.
TOTAL AMOUNT
OF PROCEEDS $ ____________________________________
Recipient Signature Recipient Signature
I have read and understand the application and qualifications for this grant. I declare under penalty of perjury
that the information provided in the application is true and correct. I further authorize the City of Fresno to
release information about this company and its use of the Save Our Small Businesses funds for disclosure
purposes. I acknowledge that the City has the right to audit the information provided on this grant’s application.
I agree to provide supporting documentation to substantiate the information on this grant’s application upon
request from the City. I attest that I have not received any prior funding from the City of Fresno under the first
round of Save the Small Businesses program, the County of Fresno HUB Grant program, or Federal PPP
financial assistance. I understand that I am receiving Federal CARE Act funding and will use the proceeds in
accordance with the guidelines. The grant proceeds will be used for:
ADMIN USE ONLY: ___ESSENTIAL BUSINESS ___ NON-ESSENTIAL BUSINESS
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Voucher-Remittance-Declaration-FORM Voucher Remittance Declaration FORM

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Completed 12 July 2020

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