Instructions:

Answer all questions completely and accurately. It is important that this form be completed in its entirety.

**IMPORTANT - do not attempt to upload any individual file larger than 20MB! If you get a file loading error, please verify ALL prior typed information is still there - often the app will 'start over' if there's a file error.

Any awarded funds may be taxable and we reserve the right to issue a 1099 at the end of the year. All grantees should consult with tax professionals when filing for 2021.

Contact/Business Information

First Name *

Last Name *

Title

Legal Name of Business *

Doing Business As (optional):

Street Address (for the BUSINESS) *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address (this is CRITICAL - all correspondence will be conducted via the email you enter here, and you agree to accept all responsibility for monitoring said email for grant-related information): *

Today's Date * +

Business Website (if any)

Legal Description of Business: *

If you responded “Other” to the previous question, please explain the nature of your business and its classification for legal and tax purposes.

Business EIN: *

State of Incorporation/Founding *

County where the business is physically located *

Does your business have more than one legal owner? *

Yes

No

List Names, Addresses, and % ownership of ALL owners, if applicable (Hit the Green "+" for additional rows) ***MAKE SURE total ownership equals 100%***

+-

Was your entity in operation prior to January 1, 2019? *

Yes

No

Please indicate all quarters your business has been in operation since 1Q 2019

Date Business Established * +

Is your business appropriately licensed and CURRENTLY operating in the County, with no plans to go out of business in the next 12 months? *

Yes

No

Is your business a for-profit entity, not publicly traded, legally operating in the state of PA, with a tangible net worth of $15 million or less? *

Yes

No

How many people (Full Time Equivalent employees, working 40 hours per week) are employed in your business? *

1-299

300+

Is your business primarily engaged in the hospitality industry? *

Yes

No

Please provide your business' NAICS code from the dropdown list below (for additional info on the categories, see the 'NAICS Code Definition' documents on the North Central Website): *

Has your business been subject to mandated closure due to the COVID-19 emergency declaration (and any renewals of that declaration) issued by Governor Wolf in March of 2020? *

Yes

No

If yes, please list dates your business was closed due to state mandate here. Please indicate whether you were fully or partially closed (ex. takeout only), reduced hours, or any other modifications to your normal operations you had to make. *

Has your business received ANY COVID-19 related funding (Grants or Loans) *

Yes

No

If yes, indicate the amount below: (Numeric values only)

	Amount
Federal SBA - PPP	Amount
Federal SBA - EIDL	Amount
State - CDFI - COVID19 Relief	Amount
State - CWCA	Amount
Federal/State Other	Amount
Local Government CARES grants	Amount
Other Local Government grants	Amount
Philanthropic Source	Amount
Other	Amount

Company Financial Data

Prepare a net profit/loss report for April 1 - Dec 31 of 2020, and then also April 1-Dec 31, 2019. There are many ways to do this, but here are the two we would prefer...please choose one:

A.) If you or your accountant use Quickbooks:

-Open your company in QB

-Click on the 'reports' tab, then click on 'Company & Financial'

-One of the options will be 'Profit & Loss Prev Year comparison'. Click that.

-The report will appear comparing 2019 and 2020 year to date. To the right of 'Dates' in the upper left will be a drop-down box, currently set to 'This Fiscal year-to-date'. Click the drop-down and select 'custom'.

-In the 'From' field enter '4/1/2020'. In the 'To' field enter '12/31/2020'.

The form should now show a complete comparison between last year and this year for the timeframe specified.

-Under 'file' click 'Save as PDF'. MAKE NOTE of where it's saved - I recommend saving it to your desktop or to your documents folder for easy access. Name it something you'll remember as well.

-Upload the file to the portal as requested.

B.) If you or your accountant do NOT have Quickbooks (or comparable accounting software):

-You can find an excel template on our website at https://www.jeffersoncountypa.com. It has tabs for both 2019 and 2020 April-December. Please fill out all the information on BOTH tabs, save it on your computer, and then upload it to the portal.

IMPORTANT NOTE: Whichever option you choose, remember that you are certifying that the information is accurate. If the state decides to run an audit and discovers that you have provided inaccurate information, they have the right to demand repayment of the grant. So please provide the most accurate data possible.

Businessowner Acknowledgements

An applicant, or its authorized representative permitted to enter into any form of contractual obligation and attest to the accuracy of the applicant’s information, hereby knowingly and voluntarily verifies the following terms and provisions for the applicant in accord with the applicant’s submission of all documentation for a grant pursuant to the COVID-19 Hospitality Industry Recovery Program (hereinafter, “CHIRP”), and, as such, therefore, knowingly agrees to ALL of the following terms and provisions:

The applicant was in operation on February 15, 2020, and, if and when required, the applicant paid income taxes to the Federal and State Government, as reported on individual or business tax returns;

The applicant remains in operation and does not intend to permanently cease operations within one (1) year of the date of application;

COVID-19 has had an adverse economic impact on the applicant which makes the request for this grant necessary to support its ongoing operations;

The applicant has been, and remains, in compliance with COVID-19 mitigation orders issued by the Commonwealth of Pennsylvania since March 2020 and shall remain in compliance thereto, and also agrees to comply with all such related orders in effect now, or as may be issued in the future, as related to COVID-19 Pandemic;

The grant will be used - in its entirety - to pay for those expenses and damages directly related to its COVID-19-related economic impacts;

During the period beginning on January 1, 2021, and ending on June 30, 2021, the applicant has not and will not receive any other, or apply for, another grant under CHIRP program unless such application pertains solely and completely to another eligible business under this program;

An applicant or the authorized representative of the applicant knowingly and voluntarily certifies that all of the information provided in the application for this CHIRP grant - and all information related thereto as may be provided in supporting documents and forms - is true, complete and accurate in all material respects as such information pertains to the business operations of the applicant;

The applicant completely understands and voluntarily agrees that making any false statements to obtain a grant under this CHIRP program is punishable by the penalty of perjury pursuant to the laws of the Commonwealth of Pennsylvania pursuant to 18 Pa.C.S. § 4904 (relating to unsworn falsification to authorities), and shall be prosecuted to the fullest extent of the law.

I acknowledge all of the above. *

Yes

No

Attach a W-9 form here (if you don't already have a w-9, go to https://www.irs.gov/pub/irs-pdf/fw9.pdf) : *

Attach your 2019 BUSINESS Income Tax return (or Schedule C, if that's how you file) here: *

Attach your Profit/loss statement here (If you have 2 files, upload 2019 here and 2020 below) *

Attach your 2020 Profit/Loss statement here, if necessary

Attach your 2020 tax return here, if available (if you have not yet filed you may skip this)

When you submit, you will see a 'success' page with a reference number. If that does not happen, you DID NOT complete the application!

Questions? Contact Jamie Lefever, phone 814-849-1517 or email jlefever@jeffersoncountypa.com

Please Click Checkbox below to indicate you are an actual person

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