Colorado



Direct Aid Application for Small BusinessTown Point of Contact: Jeff Schreier, Town Administrator – 970-454-3338Name of Business: Business Trade Name:Name of Individual/POC:Phone Number:Email:Business Address:Preferred type of payment Appointment to Pick up checkAppointment for check delivery to business addressCheck by mailDoes your business operate within the Town of Eaton: ( yes / no )Business/Industry Sector:Restaurant BarMovie theater Fitness and recreational Sports centersSize of Business (annual revenue):Type of business (corporation, LLC, partnership, sole proprietor):Date business established: Number of employeesNumber of full-time employees:Number of part-time employees:Provide Colorado income tax account number (Form W9) or, if exempt from filing a Colorado income tax return, the Colorado tax exempt certificate numberProvide receipt of most recent payment of unemployment insurance payroll taxesProvide 2019 tax return (for funding allocation)For businesses that commenced operations prior to January 1, 2020, provide evidence of at least twenty percent revenue loss since March 26, 2020 due to the restrictions imposed by Governor or the Colorado Department of Public Health and Environment’s COVID-19 ordersI self-certify (checkboxes):My business is in good standing with the Secretary of State. ( yes / no )My business is headquartered in Colorado. Headquarters is defined as the location where the principal business and management decisions are made for the business. ( yes / no )I have had at least 20% revenue loss due to effects of the COVID 19 public health crisis since March 26, 2020, or my business began between Jan 1, 2020, and March 26, 2020. ( yes / no )I plan to stay in business for at least 6 months. ( yes / no )My business is in compliance with the executive orders pertaining to the public health emergency due to COVID-19 and all applicable statewide and local public health orders, including capacity restrictions. ( yes/no )I pledge to use these grants to pay for business expenses including but not limited to salary, rent, utilities, inventory, equipment, interest or principal on business loans and other business uses. ( yes / no )I have not applied for other SB20B-001 funds, which include the arts relief program or minority business program. ( yes / no )I understand that the statements in this application are subject to verification and validation and I may be asked to provide documentation including financial or banks statements and other documents supporting their accuracy during subsequent follow-up communications with the State of Colorado, their agents or the Town of Eaton and I will cooperate in providing such information. ( yes / no )I agree to retain documents to verify the information requested herein. I am aware that I may be audited and asked to provide these documents to justify my award. If I am not able to validate the accuracy of these statements, I understand I may be asked to pay back this award and/or be subject to legal remedies. ( yes / no )I understand that, pursuant to SB 20B-001, if my business ceases to comply with local or state public health orders, my business shall be required to return funds received hereunder.?( yes / no )I understand that if I knowingly provide any inaccurate information on this application, I will be subject to penalties, including potential repayment of any funds received and any appropriate legal action. ( yes / no )While the Town will endeavor to protect confidential information as provided by law, I understand that information submitted herein may be subject to disclosure under the Colorado Public Records Act, Section 24-72-200.1, et seq., C.R.S.I certify that I am an officer of the above-named company with the authority to sign on its behalf. ( yes / no )I swear and affirm that all of the statements contained herein are true and accurate to the best of my knowledge. By: __________________________________Name:Title: ................
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