City of Hercules
Small Business Assistance Grant
Program Application
draft
Business Information
Business Name:
___________________________________________________________________________ Business Owner Name:
___________________________________________________________________________ Business Location Address:
___________________________________________________________________________ Business Owner Mailing Address:
___________________________________________________________________________ Business Owner Phone: ____________________________________ Business Owner Email: _____________________________________ Independent Contractor: Yes ____ No ____
Number of employees at all Hercules locations: ________ Date Established (Earliest date if more than one Hercules location): ______________ City of Hercules Business License Number: ____________________________________ Business Type: ________________________________________________________ Primary Business SIC Code(s): ___________________________________________ Description of Lost Revenue
Describe the revenue that your business has lost due to COVID-19:
____________________________________________________________________________ ____________________________________________________________________________ Attach documentation illustrating loss of revenue due to COVID-19 Attach copy of IRS Form W-9
Other Information
*Does not impact eligibility for the Hercules Small Business Assistance Grant Program* Indicate any form of government assistance your business has received related to COVID-19:
Economic Injury Disaster Loan (EIDL) Yes ___ No ____ Did not apply ____ Paycheck Protection Program (PPP) Yes ___ No ____ Did not apply ____ Other government assistance received:
________________________________________________________________________ If your business is an independently owned franchise, have you received any corporate assistance? Yes ____ No ____ Did not apply ____
Briefly explain:
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Indicate primary intended use of Hercules Small Business Assistance Grant Program funds:
Protective and safety equipment Yes ____ No ____ Utilities Yes ____ No ____ Employee training Yes ____ No ____ Rehiring Yes ____ No ____
COVID-19 grant/ loan application
processing Yes ____ No ____
Financial training Yes ____ No ____
E. Other:
_________________________________________________________________________ Have you fully reopened your business?
Yes ____ No ____
If “No,” briefly explain:
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ Optional Demographic Information: Responses to the following questions are voluntary and will be used solely for statistical purposes. They will not be used to determine eligibility.
Is the business minority-owned? Yes ___ No ____ Is the business women-owned? Yes ___ No ____ Is the business veteran-owned? Yes ___ No ____ Owner Attestation
I hereby certify the truth of this application, confirm that my business is in full compliance with all local, State, and federal laws, including COVID-19 related health orders, and acknowledge that any false statements in it shall, at the City’s option, result in automatic invalidation of the action based thereon.
Owner Signature: ________________________________ Date: _____________________