La Verne Grant Application The City of La Verne has partnered with the La Verne Chamber of Commerce (Chamber) to develop a Small Business Rescue Grant Program, funded through the American Rescue Program Act to provide vital economic support to small businesses needing assistance as a result of business interruption caused by COVID-19. Small businesses negatively affected by COVID-19 may be eligible to receive a working capital grant of up to $10,000. The grant may be used for business operating expenses incurred as a result of COVID-19, such as social distancing or for operating expenses such as rent/mortgage, payroll and benefit costs, utility expenses, etc. BUSINESS INFORMATION Fields marked with * are required Business Name:* Business Employer Identification Number (EIN) or Social Security (SSN):* City of La Verne Business License Account No.:* Business Owner Name:* Business Address:* Mailing Address:* Business Phone:* Contact Phone:* Email:* Website Business Structure:* Sole ProprietorLimited LiabilityS-CorporationC-CorporationPartnership Date Business Established:* Number of Employees:* Full Time Part Time Type of Business:* HospitalityRestaurantPersonal ServicesRetailTechnologyManufacturingOther Briefly describe the service or product your business provides:* COVID-19 BUSINESS INTERUPTION The La Verne Small Business Rescue Grant is intended to cover fixed expenses specifically associated with losses and hardships endured during the COVID-19 Pandemic. Please check all of the below boxes that apply to your business:* Revenue from the 2020 or 2021 calendar year was down in comparison to revenue from the 2019 calendar year; AND, the amount of lost revenue equals or exceeds the amount of requested assistance (up to $10,000). My business incurred losses due to the forced shutdown by the state or local government. My business incurred added expenses due to COVID-19 regulations and the amount of expenses equals or exceeds the amount of requested assistance (up to $10,000). My business suffered losses due to one or more employees contracting COVID-19. Please briefly explain any other hardships or recurring costs (such as rent) that you would like to bring to our attention in consideration of this grant (if not applicable, enter NA): DEMOGRAPHIC INFORMATION The City would appreciate you taking a moment to provide some basic demographic information to help us understand our business community and tailor future programs and services to local interests. Is your business more than 51% (check all that apply): Minority-ownedWoman-ownedVeteran-owned What is your gender identity: FemaleMaleNon-binaryPrefer not to disclose Which of the following best describes you: Asian or Asian AmericanBlack or African AmericanHispanic or LatinoWhite or CaucasionMulti- or Bi-RacialIndigenous or Alaskan NativeNative Hawaiian or other Pacific IslanderOther: GRANT REQUEST – GRANT SPENDING PLAN In the section below, please explain how you will use the La Verne Grant Funds if approved. Amount of funds requested (max amount $10,000):* Recover Lost Revenue: Expenses: Please check one: Rent or Mortgage AnticipatedIncurred Payroll Costs AnticipatedIncurred Facade Improvements* AnticipatedIncurred Outdoor Operations* AnticipatedIncurred Hiring Bonus** AnticipatedIncurred Utility Bills AnticipatedIncurred Updates to Employee Handbook AnticipatedIncurred Personal Protective Equipment AnticipatedIncurred Other COVID19 Operational Expense AnticipatedIncurred Please describe other expense: *Façade Improvements must be in a public facing area (for visual improvements), outdoor operations must be for public- consumer gathering areas. **Hiring Bonus is made to employee for employers who have had a difficult time attracting new employees. The bonus should be given after 6 months of employment. Capped at $1,500 per employee. REQUIRED DOCUMENTS Current City of La Verne Business License:* Completed and signed W-9:* You must also submit one or both of the following Spending Plan or Invoices & Billing Statements demonstrating expenses: 2019 Federal Tax Return: 2020 or 2021 Federal Tax Return: The City reserves the right, in its sole and absolute discretion at any time: (1) to amend or terminate this program with no recourse for any proposing applicant; (2) to choose or reject any or all applications received in response to this program; (3) to request additional information of the applicants as deemed necessary and appropriate by the City; (4) to conduct further due diligence with applicants or any third party; (5) to modify the City's objectives or the scope of the program; (6) to modify program requirements, general terms and conditions, or eligible activities; and/or (7) to disqualify any proposing applicant on the basis of any real or perceived conflict of interest that is disclosed or revealed by materials submitted or by any data available to the City. By submission of this application with documentation, applicant agrees to these terms. ACKNOWLEDGEMENT, ATTESTATIONS AND CERTIFICATION Acknowledgement:* I/We understand that this grant is being provided by the City of La Verne based upon the information and documentation that I/we have provided in this application. I also confirm that there are no outstanding tax liens or legal judgments against the business. Attestations:* The business experienced a loss in revenue when comparing total revenue from calendar year 2020 or 2021 to total revenue from calendar year 2019. The business has a minimum of at least one employee and does not exceed a maximum of twenty-five (25) full or full-time equivalent employees (two part-time employees equal one full-time employee). Spending Plan and Certification that funds will be spent by December 31, 2023. Certification that the financial records submitted are true and accurate. Certification grant amount spending records will be available for audit when requested. The business agrees to maintain all records pertaining to the grant for at least 6 years. Certification:* I/We also agree that this application authorizes the City, the Chamber and their agents to verify all sources of incomes and/or including, but limited to, the submittal of a request to the Employment Development Department/Unemployment Agency to verify any unemployment benefits currently being received by the business owner. I/We also agree that this form authorizes the City, the Chamber and their agents to verify the business owner(s) alternative grants received for this business in connection with coronavirus pandemic and/or American Rescue Plan Act of 2021. By signing below, I/we certify that the above information and statements are true and correct to the best of my/our knowledge. I/we understand that a false statement may disqualify me/us. Owner Signature:* Co-Owner Signature What is 2+2?