Hidden-Lebanon County Cares Grant Application Please submit your application below for Phase 2 of Lebanon County CARES Grant. Incomplete or incorrect applications will not be considered. Applications for round two must be submitted between October 15-30. Fund rules, information, and an FAQ document can be found at LebanonCountyCares.com. You can also find a step-by-step guide on the application portal at LebanonCountyCares.com. * RequiredWe are applying for* Non-Profit Tourism/Hospitality Small Business (less than 100 employees) Sec A: Applicant Information1. Entity Legal Name* (If different than above) Business Name or DBA 2. Employer Identification Number (EIN)*Enter all zeros if no number I do NOT have an EIN Social Security Number (If no EIN) 3. Please select the industry option that most closely represents the majority of the applicant’s activities.* Accommodation/Hospitality/Restaurant Business/Professional Services Retail Agriculture Healthcare Manufacturing/Distribution Non-Profit Construction Gym 4. Brief Summary of Services or Goods Produced*Please limit to 2000 characters or approx. 300 words.5. NAICS Code*Search for your code. 5a. First Year of Operations*MUST be a 4 digit year. 6. Number of FULL-TIME employees as of March 1, 2020* 6a. Number of PART-TIME employees as of March 1, 2020* 7. Please check all that apply for your business (optional)for informational use only: African-American owned Hispanic-owned Asian-American owned Woman-owned Other minority-owned Disabled-owned Veteran-owned Sec B: Business Location8. Street Name* 8a. City* 9. Zip Code* 9a. Municipality* Sec C: Mailing AddressIf different than above for fund distribution.10. (Mailing) Street Name 10a. (Mailing) City 10b. (Mailing) Zip Code Sec D: Primary Contact11. Name* First Last 12. Title* 12a. Phone*13. Email* Sec E: Additional Business Information14. Lebanon County is applicant’s* Only or headquarters location Branch location with headquarters in another county 15. Legal Structure*Multiple options allowed. Corp LLC LLP Sole Proprietorship Partnership Non-Profit Sec F: Financial Impact Information16. Please describe the current and projected future impact of COVID-19 to your operations and intended use of funds.*Please limit to 3000 characters or approx. 500 words.17. Total Revenue March 1 to July 31, 2019*Do not add dollar sign.17a. Total Revenue March 1 to July 31, 2020*Do not add dollar sign.17b. Total gross revenue reported on most recent year’s submitted tax return or full-year financial statement*Do not add dollar sign.18. Total operating expenses reported on most recent year’s submitted tax return*Do not add dollar sign.19. Net Profit or Loss (line 31 Schedule C) or revenue less expenses (line 19 on 990) reported on most recent year’s submitted tax return*Do not add dollar sign.20. Amount of grant requested*(Please review guidelines in FAQs by annual revenue) Do not add dollar sign.21. Check this box if your need exceeds the maximum grant request allowed per annual revenues. Please review this application as an exception to the grant request limitations. 22. We received the following in CARES Act Funding to date:*(Paycheck Protection Program or EIDL Advance) More than $50,000 $30,001-$50,000 $15,001 and $30,000 $5,001-15,000 Up to $5,000 None 23. What are your current and expected revenue losses (March 1-Dec. 31) due to cancelled fundraisers/events?*(For nonprofits only) More than $30,000 $20,001-$30,000 $10,001 and $20,00 $5,001-10,000 Up to $5,000 None 24. Please confirm your registered designation:*(For nonprofits only) 501(c)(3) 501(c)(19) Note: Questions 23 and 24 are only visible and applicable to Non-Profit entities as selected at the top of this form.25. What are your un-budgeted expenses (to-date) as a direct result of COVID?* More than $30,000 $20,001-$30,000 $10,001 and $20,000 $5,001-10,000 Up to $5,000 None 26. Were you considered an ‘essential business’ during Pennsylvania’s stay-at-home orders?* Yes No 27. What is your current operating status?* We cannot operate at all due to current restrictions We can only operate up to 25% capacity We can only operate up to 50% capacity We can only operate up to 75% capacity We can operate at full capacity Sec G: You must include the following:Applications will not be considered complete unless all supporting documents are uploaded.Please use the document upload field below to upload all documents.Please include the following: – Internal financial statement or summary of March-July 2019 revenues* – Internal financial statement or summary of March-July 2020 revenues* – Most recent year’s submitted federal tax return or most recent full-year financial statement*– Non-profit determination letter from the IRS or other official document showing non-profit status (non-profit only)* Document Upload*Allowable file types: pdf, doc, docx, xls, xlsx, jpg, gif, odt, ppt, pptx, jpg. Maximum 10 files at 25mb. Drop files here or Select files Accepted file types: pdf, doc, docx, xls, xlsx, jpg, gif, odt, ppt, pptx, jpg, Max. file size: 25 MB, Max. files: 10. Sec H: Lebanon County CARES Grant Certification by ApplicantThe Applicant certifies that:*1. All information and statements contained in this Application, and all documents and exhibits submitted with this Application, are to the best of Applicant’s knowledge, true, accurate, complete, and not misleading, as of the date of this Application. Any further information or documentation submitted by Applicant in connection with this Application shall also be subject to this certification, which shall be deemed to be remade as of the date submitted. 2. Applicant has fully complied with, and will fully comply with, all federal, state and local laws, regulations and orders applicable to this grant and applicable to Applicant’s business, assets and/ or operations, and the Applicant is not currently under investigation with respect to any violation of, or other failure to comply with, any such applicable law or regulation. This includes following all emergency orders by the Governor and Secretary of Health and operational restrictions under the Governor’s reopening plan. No funds will be used for any purpose or in any manner that violates federal, state or local laws or regulations. All funds will be utilized for purposes consistent with the Coronavirus Aid, Relief, and Economic Security Act (the “CARES Act”). 3. The Application is based on the Applicant’s reasonable estimate of financial need for, and all funds will be utilized by the Applicant solely for, working capital, operational costs or COVID-19 health or safety related expenses necessary to maintain or continue the Applicant’s operations in Lebanon County, Pennsylvania, including (without limitation) payroll, rent, mortgage interest, supplies, personal protective equipment and other operating expenses, and retrofitting capital costs, and all funds received from this program by Applicant shall be used for such purposes. 4. Applicant will submit additional information and documentation in support of this application and/or the grant requested or awarded with respect to this Application, in each case, upon request, and will permit the County of Lebanon or its representatives, designees or affiliates to inspect and/or audit the books, records, premises and operations of the Applicant to assure compliance with the requirements of this program. Applicant hereby acknowledges and agrees that all information may be shared by and with the County of Lebanon, Pennsylvania, and the commissioner-appointed application review committee to the extent such disclosure is made in connection with the application and this grant program. 5. AVAILABLE FUNDS ARE LIMITED AND SIGNIFICANT INTEREST IS ANTICIPATED. Applicant recognizes that there is no assurance that Applicant will be awarded any grant of any size, regardless of how well the Applicant may meet the criteria used for awarding these grants and regardless of what the Applicant may have been told or read with respect to this grant program. As a condition and in exchange for the consideration of receiving and reviewing this application, the Applicant hereby releases and will hold harmless the County of Lebanon, Pennsylvania, the Lebanon Valley Chamber of Commerce, the United Way of Lebanon County, Lebanon County Tourism Promotion Agency, Inc., Garcia Garman & Shea, PC and their respective partners, designees and affiliates in facilitating and administering this grant program and their respective Board of Commissioners, Boards of Directors, officers, employees, representatives, volunteers and committees of and from any and all claims and/or causes of action of any kind or type arising from or out of (a) their receipt and review of this application and any information or documentation of or concerning the Applicant, (b) any decisions or recommendations with respect to this application, (c) the administration of this program and/or the award or denial of funds and/or the sufficiency thereof, and (d) any other matter or thing related to this program. 6. As a condition of Applicant’s submission of the Application and receipt of any Benefits made available under the Program, the Applicant hereby releases the County of Lebanon, Pennsylvania, the Lebanon Valley Chamber of Commerce, the United Way of Lebanon County, Lebanon County Tourism Promotion Agency, Inc., Garcia Garman & Shea, PC and their respective partners, designees and affiliates in facilitating and administering this benefit program and their respective Board of Commissioners, Boards of Directors, officers, employees, representatives, volunteers and committees of and from any claims and/or causes of action of any kind or type arising from or out of (a) their receipt and review of the Application, (b) the administration of the Program and/or distribution or delivery of the Benefits available under the Program, (c) the Benefits received by the Applicant, and (d) any other matter or thing related to the Program. 7. All decisions and recommendations with respect to this application and this grant are final when made and are non-appealable. The Applicant acknowledges that grant award determinations will be made based on both objective and subjective analysis of information available and that award determinations need not follow strictly or consistently the scoring methods utilized. The Applicant also acknowledges that the identity of funding applicants and recipients, award amounts and application scores and recommendations will become public information. 8. The individual signing below is legally authorized by the Applicant to submit this application, to sign this certification and to legally bind the Applicant. 9. The parties acknowledge and agree that this document may be executed by electronic signature, which shall be considered as an original signature for all purposes and shall have the same force and effect as an original signature. 10. By submitting this application, I agree that this application is final and cannot be edited. I agree to all of the above requirements.(Print name here) required**I certify all information on this application is truthful and complete to the best of my knowledge and I am authorized to submit this application. I acknowledge that the County is relying on this application to determine eligibility for this grant, and any false information will result in the repayment of grant funds back to the County. I verify the facts set forth in this application are true and correct to the best of my knowledge, information, and belief. This statement is made subject to the penalties of Section 4904 of the Crimes Code (18 PA. C.S. § 4904) related to unsworn falsification to authorities. Signature* Reset signature Signature locked. Reset to sign again CommentsThis field is for validation purposes and should be left unchanged. Once you hit submit, please make sure you go to a Thank You screen and look for a copy of your application in your email.