City of Hercules
Small Business Rent 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 COVID-19 Impacts
Please indicate how many full-time equivalent staff (FTE) you had at the end of 2019 including yourself ___________________________________________________________________ Please indicate how many full-time equivalent staff (FTE) you had at the end of 2020 including yourself___________________________________________________________________ Please indicate how many full-time equivalent staff (FTE), including yourself, that you currently have______________________________________________________________________ Please indicate your monthly rent expense________________________________________ How much back rent do you owe________________________________________________ Please note that the grant will not exceed $15,000.
What was your income for the whole year of 2019___________________________________ (Businesses that started in 2020 but before the COVID-19 pandemic should enter $0 income for 2019. Additional measures of impact and viability will be requested.) What was your income for the whole year of 2020____________________________________ How many months was your business partially or fully closed due to COVID19 regulations___________________________________________________________________ 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
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:
____________________________________________________________________________ ____________________________________________________________________________ ____________________________________________________________________________ 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: _____________________