Naperville



Small Business Assistance Grant Application: Part I - Screening QuestionnaireTop of FormIf you are a business owner with a business located in Naperville that is being negatively impacted by COVID-19, please consider applying for the Small Business Assistance Grant. To determine if you are eligible, please read the program Fact Sheet located at: . To apply for the grant, answer all questions in Part I below by checking the box next to either “Yes” or “No”.Business LocationMy business is located within the incorporated boundaries of the City of Naperville?Yes ?NoBusiness Status2.? My business is currently open and not in bankruptcy?Yes ?NoBusiness in Good Standing3.? My business is in good standing with the City of Naperville, has all required permits and licenses, complies with all regulations and is up-to-date on all fees ?Yes ?NoBusiness Taxes4.? My business is current on all federal, state and local taxes ?Yes ?NoLength of Time in Operation5.? My business began operating prior to January 1, 2020 ?Yes ?NoBusiness Size (Number of Employees)6.? My business has 50 or fewer full-time equivalent (40 hours per week) employees, including the owner(s) ?Yes ?NoBusiness Size (Revenue) 7.? My business had less than $2,000,000 in annual revenue in 2019 ?Yes ?NoBusiness Type8.? My business does not include any of the following: home-based, nonprofit, religious or political organization, payday loan, real estate investment or rental property management, rooming house/boarding facility/air bnb, adult entertainment ?Yes ?NoFranchise or Chain9.? If my business is part of a franchise or chain, this location is the only location in Naperville that will apply for a grant ?Yes ?NoCOVID-19 Impact10.?My business has been negatively impacted by COVID-19 (lost sales/revenues, reduced staff, increased expenses due to health-requirements, etc.) ?Yes ?NoNeed for Grant Funds11.?A grant of up to $5,000 will help my business to remain open and retain current employees or hire new employees ?Yes ?NoBusiness Information12.?As the business owner, I certify that I am able to provide business information, including the legal name of the business, my SSN or EIN and birthdate, plus the business DUNS (Dun and Bradstreet) Number or will get a DUNS number (Get a DUNS number at: ) ?Yes ?NoFinancial Assistance Information13.?As the business owner, I certify that I am willing to disclose all other financial assistance that my business has received from federal, state, local, private, nonprofit and/or charitable sources and how this assistance has been used ?Yes ?NoIf you were able to answer “Yes” to all the above questions, continue to Part II. If not, your business is not eligible for grant funds. Small Business Assistance Grant Application: Part II – Business Information Complete all questions shown below:Eligibility:1.1 Have you completed and answered “YES” to all questions on Part I: Screening Questionnaire? ? YES ? NO(If NO, your business is not eligible; do not complete the rest of the application)1.2 In addition to the conditions on the Screening Questionnaire, your business must fit in one of 2 categories described below. Check the category that best fits your business:? Category #1 – MICROENTERPRISEA Microenterprise has five or fewer employees at the time the application is submitted, including the owner.Owner’s current household income considered low to moderate income, based on household size, as shown in the chart below.The number of people in the household includes the head of the household and everyone related to him or her by birth, marriage or adoption. The household income is the combined total income of all household members 18 years old or older.Household Size (Number of Persons)1 Person 2 Persons3 Persons4 Persons5 Persons6 Persons7 Persons8 PersonsHousehold Income $51,000$58,250$65,550$72,800$78,650$84,450$90,300$96,100? Category #2 – SMALL BUSINESS JOB CREATION or RETENTIONA business with 6 – 50 employees or a microenterprise whose owner’s household income is higher than low to moderate-income. The business agrees to do one of the following (Check one):? Job Retention: Retain at least one existing full-time equivalent (40 hours per week) job. The employee’s current personal income must be at low to moderate, as shown in the chart above. Part-time job hours can be added together to total one full-time job.? Job Creation: Create at least one new full-time equivalent (40 hours per week) job. The employee’s current personal income must be low to moderate, as shown in the chart above. Rehiring of laid-off or furloughed employees counts as job creation. Part-time job hours can be added together to total one full-time equivalent job.Primary Contact/Legal Representative Information:2.1 Business Owner/Legal Representative Name (Primary Contact): Click here to enter text.2.2 Home Address: Click here to enter text.2.3 City, State, Zip Code: Click here to enter text.2.4 Home Phone Number: Click here to enter text.2.5 Cell Phone Number: Click here to enter text.2.6 Email Address: Click here to enter text.2.7 Date of Birth: Click here to enter text.Business Information:3.1 Applicant Business Legal Name: Click here to enter text.3.2 If D/B/A, what is the D/B/A name? Click here to enter text.3.3 Business Address: Click here to enter text. 3.4 City, State, Zip Code: Click here to enter text.3.5 Business Phone Number: Click here to enter text. 3.6 Business Email Address: Click here to enter text. 3.7 Business Website: Click here to enter text.3.8 List all business owners, percentage of ownership and length of time owned: Owner NamePercent of OwnershipHow long owned? FORMTEXT ????? FORMTEXT ?????% FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????% FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????% FORMTEXT ????? FORMTEXT ????? FORMTEXT ?????% FORMTEXT ?????3.9 Business Type: ? LLC ? Partnership ? Sole Proprietor ? Other3.10 Business Tax Identification Number (TIN) or Employer Identification Number (EIN): Click here to enter text.3.11 DUNS Number: Click here to enter text. (DUNS Number is required – look yours up or get one here: ) Business Background:4.1 How long has business been in operation? Click here to enter text.4.2 Is the business currently open? Click here to enter text.4.3 Length of time at current address: Click here to enter text.4.4 Do you own or rent your space: ? Own ? Rent (If rented, please provide landlord contact information:Landlord Name: Click here to enter text.Landlord Address: Click here to enter text.Landlord Phone Number: Click here to enter text.Landlord Email Address: Click here to enter text.4.5 Please provide a brief description of the business, experience in the industry and operations in Naperville: FORMTEXT ?????5.0 Need for Funding Due to COVID-19 Pandemic Impact: 5.1 Briefly describe how COVID-19 has affected your business, including lost revenues, reduced production, employees laid off, forced closure and reopening, additional expenses necessary to meet public health requirements (PPE, social distancing, etc.): FORMTEXT ?????5.2 Briefly describe any other changes to your business operations as a result of COVID-19, including additional expenses you may incur in the future in order to continue operating: FORMTEXT ?????5.3 Complete the table below showing the number of full-time and part-time employees your business had before the pandemic and currently:Total EmployeesPre-Pandemic: March 1, 2020Current: November 1, 2020Full-Time FORMTEXT ????? FORMTEXT ?????Part-Time FORMTEXT ????? FORMTEXT ?????5.4 Complete the table below listing the job titles and hours worked for current employees:Job TitleHours Per WeekNumber of Employees in this PositionExample: Owner/Manager401Example: Waiter204Revenue Impact:5.5 Complete the table below for pre- and post-pandemic business expenses and revenuesExpenses(monthly or average monthly)Pre-Pandemic(before March 1, 2020)Post-Pandemic(after March 1, 2020)Rent/Mortgage Cost$ FORMTEXT ?????$ FORMTEXT ?????Nicor (gas company)$ FORMTEXT ?????$ FORMTEXT ?????Payroll$ FORMTEXT ?????$ FORMTEXT ?????Insurance$ FORMTEXT ?????$ FORMTEXT ?????Inventory$ FORMTEXT ?????$ FORMTEXT ?????Supplies/Equipment$ FORMTEXT ?????$ FORMTEXT ?????Other (please describe below)$ FORMTEXT ?????$ FORMTEXT ?????Total Monthly Expenses$ FORMTEXT ?????$ FORMTEXT ?????Total Monthly Revenue$ FORMTEXT ?????$ FORMTEXT ?????6.0 Use of Grant Funds: 6.1 How will the grant funds you are requesting be used? List and describe all the expenses the grant funds will be used to pay for and whether they are delinquent, current or future:EXAMPLE:Business Expense DescriptionDelinquent AmountCurrent or Future AmountTotal Expenses to be ReimbursedExample: Partial rent of $1,000/month for April and May, 2020.$2,000.00$0.00$2,000.00Example: Cost of PPE’s for November, 2020.$0.00$600.00$600.00Example: Payroll for 1 Chef working 20 hours/week at $15/hour for 2 months$0.00$2,400.00$2,400.00TOTAL EXPENSES$2,000.00$3,000.00$5,000.00YOUR ESTIMATED EXPENSE REQUEST:Business Expense DescriptionDelinquent AmountCurrent or Future AmountTotal Expenses to be Reimbursed FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ????? FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????TOTAL EXPENSES$ FORMTEXT ?????$ FORMTEXT ?????$ FORMTEXT ?????7.0 Availability of Other Funding: 7.1 Please list other funding you have applied for to meet your business expenses. Include all types of funding – federal, state, county, local, private and nonprofit. Examples: Federal Paycheck Protection Program, Small Business Administration (SBA) grants and loans, Coronavirus Relief Fund, State of Illinois Business Interruption Grant (BIG), State of Illinois Emergency Loan Program, Red Cross, etc.Name of Grant or Loan:Outcome:Describe how funds were used or will be used, including amount spent and amount remaining: FORMTEXT ??????Funding Awarded: $ FORMTEXT ??????Funding Denied?Awaiting Response FORMTEXT ????? FORMTEXT ??????Funding Awarded: $ FORMTEXT ??????Funding Denied?Awaiting Response FORMTEXT ????? FORMTEXT ??????Funding Awarded: $ FORMTEXT ??????Funding Denied?Awaiting Response FORMTEXT ????? FORMTEXT ??????Funding Awarded: $ FORMTEXT ??????Funding Denied?Awaiting Response FORMTEXT ????? FORMTEXT ??????Funding Awarded: $ FORMTEXT ?????? Funding Denied? Awaiting Response FORMTEXT ????? FORMTEXT ??????Funding Awarded: $ FORMTEXT ?????? Funding Denied?Awaiting Response FORMTEXT ????? FORMTEXT ??????Funding Awarded: $ FORMTEXT ??????Funding Denied?Awaiting Response FORMTEXT ?????8.0 CertificationsI certify that I have read the entire application and instructions and that the information provided in this application is true and accurate. I realize that knowingly providing false or misleading information will disqualify me from receiving funds and may result in penalties.I understand that if my application is chosen for additional evaluation, I will be required to provide supporting documentation, which may include personal and business income tax forms, other documentation of income and business revenues, payroll documentation, receipts and invoices, and other items deemed necessary by the City of Naperville. I further understand that failure to provide required information will result in disqualification of my application.I certify that any funds I receive from the City of Naperville will be used to pay only for approved and documented expenses for which I have not received financial assistance from any other source. I further agree to repay the City of Naperville for any expenses that are determined to have received funding from other sources.I understand that if my business is chosen to receive grant funds, I will be required to sign an Agreement with the City of Naperville to comply with regulations of the U.S. Department of Housing and Urban Development (HUD) and to enable grant funds to be released to my business. I certify that I am not an employee or elected official of the City of Naperville, nor am I an immediate family member of an employee or elected official of the City of Naperville.This application must be signed by all owners of the business identified in Question 3.8:Business Owner Name: Click here to enter name.Business Owner Signature: Enter Signature ?Business Owner Name: Click here to enter name.Business Owner Signature: Enter Signature_____________________________________________ Business Owner Name: Click here to enter name.Business Owner Signature: Enter Signature_____________________________________________ ................
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