CARES Grant Application Program – Lake County Economic Development Corporation

Section 1 - Contact and Business Information

Authorized representative of the Business Entity shall enter completely the following information as required. Only one application per business. Incomplete applications will not be processed.

Business Legal Name*

Business Address*

Street Address Address Line 2 City State ZIP Code

Business Phone*

Business Email*

Business Type*

If you selected "Other", please describe your business.

Applicant Contact Legal Name*

First Last

Applicant Contact Address*

Street Address Address Line 2 City State ZIP Code

Section 2 - Eligibility

Was the business established on or before March 18, 2020?*

Yes
No

Total Number of Full Time Equivalent Employees (at the time of application)*

40 hours per week = 1 FTE. If an employee works 20 hrs/week (20 divided by 40 hours) = 0.5 FTE.

Number of Days Closed Due to COVID Emergency*

How was your business negatively affected by the COVID pandemic - Check all that apply.*

Forced to Close
Workforce issues due to health or childcare concerns or school closures
Supply Chain Issues
Decrease in Tourism or Business Travel
Other

If you selected "Other" please elaborate.*

Was the business entity’s 2019 gross revenues between $25,000 and $1,000,000?

Yes
No

Upload Evidence of Reduced Revenue*

Drop files here or

To be eligible for the CARES Small Business Grant program, a business must have experienced a loss in revenue compared to 2019 due to the COVID emergency. Please provide documentation that during 2020 the business received less revenue than 2019. This can be shown in monthly or quarterly Profit & Loss statements or bank statements. You can upload up to 6 files not exceeding 256MB.

Section 3 - Grant Request

Please enter request amounts for each qualified expense. The total of combined request amounts must be $20,000 or less. Submitted expenses for the program MUST be paid by the business entity prior to December 30, 2020. It’s suggested that you submit expenses already paid whenever possible. PLEASE NOTE: Grants will be awarded up to $20,000 at this time. In the event there is more funding made available, and your business has incurred and provided documentation beyond $20,000 (but no more than $30,000) additional grant allocations may be made. It is strongly suggested you provide documentation up to $30,000.

Amount Requested - Mortgage/Lease payment

Upload Proof of Mortgage/Lease Expense

Drop files here or

Amount Requested - Utility Costs

Upload Proof of Utility Costs

Drop files here or

Amount Requested - Payroll Costs

Upload Proof of Payroll Costs

Drop files here or

Amount Requested - Cleaning supplies, face masks, or social distancing notification expenses.

Upload Proof of Cleaning Supply Expenses

Drop files here or

Other COVID Related Expenses

(Examples: online ordering platform costs, outdoor seating equipment, loss of perishable goods during closure)

Upload Proof of Other Expense

Drop files here or

Total Amount Requested*

Max amount permitted is $20,000.

Caution: The maximum amount requested must be $20,000 or less. Please reduce the amounts you are requesting.

Statement of No Prior Application or Funds*

I have not submitted application or received federal funds for the specific expenses submitted in this application.

Upload a Copy of Government-issued, photo identification (e.g. Driver’s License Passport)

Upload a Copy of W9

Upload a copy of current payroll report confirming no more than 20 Full Time Equivalent (FTE) employees, if not provided above.

Drop files here or

Upload Business License (Optional)

Upload Fictitious Business Name Statement (Optional)

By checking boxes below, the authorized representative of the Business Entity affirmatively certifies in good faith as follows:*

Business Entity’s principal place of business (i.e. address) is located within the County of Lake, California.
Business Entity is a Sole Proprietorship, LLC/LLP, S-Corporation or Partnership and has filed a fictitious business name statement with the County of Lake and/or business license with City jurisdictions.
Business Entity has no more than 20 employees for whom it paid salaries and payroll taxes, or paid independent contractors.
Business Entity has and plans to operate in full compliance of the COVID-19 Lake County Public Health order and subsequent amendments.

Section 4 - Program Guarantees & Authorizations

By checking boxes below, the authorized representative of the Business Entity affirmatively certifies in good faith as follows:

I acknowledge that the County may confirm the eligible grant amount using required documents submitted.
I understand, acknowledge and agree that the County can share any tax information that I have provided with the grant coordinator and with appropriate federal and state governmental agencies, for the purpose of program compliance and reviews.
I acknowledge that I will provide proper documentation as requested by the County to assure the fund will be utilized for eligible purposes. The Business Entity and /or I will immediately provide proper documentation verifying the number of Full-Time Equivalent (FTE) employees on the Business Entity’s payroll, payroll costs, covered mortgage payments, covered rent payments, covered utilities and/or other relevant information additionally requested by the County.
Current economic uncertainty makes this grant request necessary to support the continuing operations. Grant funds will be used exclusively to 1) retain existing workers, 2) make mortgage or rental lease payments, 3) utility payments, or other eligible small business related expenses. Grant funds will not be used for personal expenses. If the funds are knowingly used for an unauthorized purposed, the County may hold the Business Entity and/or Owners jointly and severally legally liable.
I will comply, wherever applicable, with state and municipal ethics laws, including disclosures of nepotism, conflicts of interest and other related requirements.
All or some documentation associated with this application may become public and Business Entities should not assume any right of confidentiality in any information disclosed as part of this application.

Section 5 - Business Entity/Owner Background

Authorized representative of the Business Entity certifies in good faith as follows: IF YES, Check. IF NO, leave blank.

The Business Entity or any Owner is presently suspended, debarred, proposed for debarment, declared ineligible, or voluntarily excluded from participation in this program transaction by any federal or state department of agency.
Any Owner is subject to an indictment or criminal information regarding theft or embezzlement, or other means by which formal criminal charges are brought in any jurisdiction.
An Owner has within the last five (5) years, for any felony offense, been 1) convicted, 2) pleaded guilty, or 3) pleaded no contest.

Section 6 - Certifications and Authorizations

By signing below, the Business Entity and/or Owner make the following representations, authorizations, and certifications. I certify that:

I am authorized representative of the above referenced Business Entity.
I have read the statements included in this application, and I understand them.
Information I have provided in this application and all supporting documents and forms are true and accurate in all materials aspects.
I understand that knowingly making a false statement to obtain grant funds may be punishable under the law.
For Applicants who are Owners, I authorize the County to request criminal record information about me from criminal justice agencies for the purpose of eligibility for this program.
Upon being awarded grant monies, I ensure that I will follow all federal, state and County of Lake guidelines and procedures to ensure all monies are spent legally.
Awardee or Business Entity agrees, to indemnify and hold harmless the County and Lake County Economic Development Corporation (Lake EDC), its officers, elected or appointed officials, employees, agents and volunteers from and against any and all claims, damages, losses, expenses, fines, penalties, judgements, demands and defense costs (including, without limitation, actual, direct, out-of-pocket costs and expenses and amounts paid in compromise or settlement and reasonable outside legal fees arising from litigation of every nature or liability of any kind or nature including civil, criminal, administrative or investigative) arising out of or in connection with this grant program. The awardee or Business Entity will conduct all defenses at it sole costs. By accepting money from the County of Lake and Lake EDC the awardee or Business Entity hereby acknowledges this clause and knowingly accept any liability and hold harmless the County of Lake and Lake EDC.

Signature*

Print Legal Name*

First Last

Title*

Date*