Fillable BUSINESS INFORMATION PLEASE PRINT OR TYPE COMPLETE ALL (City of Newport)

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BUSINESS INFORMATION PLEASE PRINT OR TYPE COMPLETE ALL (City of Newport)

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  • 13 check-boxes
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File type: PDF

U.S.A. forms for City of Newport

BROWSE CITY OF NEWPORT (OR) FORMS

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5/18/2020
PLEASE PRINT OR TYPE – COMPLETE ALL BOXES
Business Name (as it appears on W-9):
Business Contact:
Business Tax Identification Number, EIN (W-9):
Title:
Business Mailing Address:
Home Address:
Business Street Address:
Telephone No.:
Telephone No.:
Email:
Email:
BUSINESS INFORMATION
Business License No.: _____________ (Mark N/A if business is outside the city limits but within the Newport Urban Growth Boundary)
Number of Employees: ________ (please convert part-time employees to full time equivalent (40 hours = 1 FTE. Round to nearest quarter.)
Type of business (check one):
Restaurant
Retail/Service
Other
Is your business within the Newport Urban Growth Boundary?
Yes
No
Years in operation (check one)
1 year or less
2-5 years
5 or more
Have you received other assistance (e.g. PPP, SBA loan, etc.)?
Yes
No
Anticipated Need: $______________ (list the amount of funds you are requesting, up to $10,000)
List how will the funds be used (check all that apply, and list the amount of the grant funds you anticipate spending for each):
Payroll $_____________________
Product (e.g. Perishable food) $___________________
ATTACHMENTS: The following information must be included with the completed grant application:
• Completed IRS Form W-9; and
• Gross revenue reports for March and April of 2019 and March and April of 2020. For businesses in operation less than one-
year, gross revenue reports for January and February of 2020 will be accepted in lieu of March and April of 2019 reports; and
• Copy of a commercial lease or mortgage statement showing the property address & amount (if seeking funds for this purpose).
• Report documenting payroll expenses for January or February 2020 (if seeking funds for this purpose).
ACKNOWLEDGEMENT
I/We, the owners of the subject business, certify that all information listed in this application, and all information furnished in support of
this application, is given for the purpose of obtaining an emergency assistance grant and that such information is true, accurate and
complete, to the best of my knowledge. I understand that if any of the information is shown to be false or misrepresented, this
application may be rejected.
_______________________________________ _________________________
Owner or Authorized Agent Date
CITY OF NEWPORT COVID-19 SMALL BUSINESS
ASSISTANCE GRANT APPLICATION
5/19/2020
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BUSINESS INFORMATION PLEASE PRINT OR TYPE COMPLETE ALL (City of Newport)

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Completed 24 January 2021

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