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Madison Heights COVID-19 Business Response Grant Program Application

2. Madison Heights COVID-19 Business Response Grant Program Application

4. Business Name*

6. Contact Person*

7. Business Owner Name*

9. Business Mailing Address*

10. Business Phone Number *

12. Business Email*

13. Business Website*

15. Business Social Media

    Insert Facebook or Social Media Link

16. Number of Employees *

18. Total Grant Amount Requested *

20. Business Status*

    1. Fully Operational
    2. Reduced Staff / Hours
    3. Closed (Due to COVID-19)

22. Request Narrative/Summary:*

    Please provide a brief paragraph outlining loss of income as a result of COVID-19 and your demonstrated need for this grant opportunity

24. Proposed Use of Award: *

    Please provide a brief explanation and an itemized list of how you intend to use these grant funds if awarded.

26. 1. How Have You Adapted Your Business to Generate Revenue or Engage Customers?*

28. Please Upload Bank Statements Here *

    January through March 2020

30. Please Upload Bank Statements Here

    January through March 2019 (Optional but strongly suggested)

32. Please Upload proof of property ownership or lease agreement*

34. 1. Do you have outstanding Code enforcement actions? *

    1. Yes
    2. No

35. 1. Have you received any other financial support or awarded any grants in response to COVID-19? *

    1. Yes
    2. No

37. Please Explain *

    Explain any other financial support or grants received in response to COVID-19

39. Applicant Certification:
    By signing this application, I certify that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances* and agree to comply with any resulting terms if I accept an grant. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or administrative penalties. I understand the City may require assurances and receipts or proof of payments for grant expenditures.

    By signing this application, I certify that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances* and agree to comply with any resulting terms if I accept an grant. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or administrative penalties. I understand the City may require assurances and receipts or proof of payments for grant expenditures.

41. Name of Signer*

    First, Last

42. Date*

44. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*

    1. I Agree

Leave This Blank:


46. 1. Receive an email copy of this form.
47. Email address

    This field is not part of the form submission.

48. Submit

* indicates a required field