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* 1. Please provide the following information on the Business requesting this Grant

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* 2. If you are a business, please provide your NAICS code, if known.

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* 3. Please upload your agency's W-9 below

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* 4. If you are a Private Non-Profit applicant, please provide documentation showing IRS Tax Exempt Status

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* 5. Please describe your business/ agency and the products/services that you provide in Tuolumne County.

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* 6. How many employees does the business/agency employ?

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* 7. Please describe in detail the financial and operational impacts of COVID-19 to your business/agency.

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* 8. When did the impacts of COVID-19 begin and what is the estimated end date (use current date if effects are ongoing)

Date
Date

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* 9. What were your business/agency's revenues during the affected period?

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* 10. What were your business/agency's revenues during the same period of the prior year?

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* 11. How much funding are you requesting under this grant?

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* 12. Please describe in detail what the grant funds would be reimbursing the business/agency for. Refer to the grant instructions for examples of eligibility.

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* 13. Please upload clear and legible receipts for the amount being requested under this grant

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* 14. Have you received any other forms of financial assistance including insurance proceeds? If so, how much and what items/activities did this assistance cover?

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* 15. Does the business/agency, or the applicant have any outstanding judgements, tax liens, or pending lawsuits against them?

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* 16. Is the applicant currently suspended or debarred from contracting with the Federal Government or receiving federal grants or loans?

By submitting this survey, the applicant is affirming that they have read and understand the Business Assistance Grant Program  and acknowledge agreement to the following terms and conditions:

Upon approval of this application, as evidenced by receipt of an approval letter, this application becomes a binding contract between the entity named above and the County of Tuolumne.

The applicant is the duly authorized representative of the entity named above and can bind the entity to the terms of this agreement.

In no event shall the County’s financial responsibility exceed the approved amount set forth in the approval letter.

The applicant will bear full responsibility for any and all tax consequences of receiving grant funds including, but not limited to, issuance of a 1099 by the County.

Applicant shall defend and indemnify the County and its employees from and against any claim, injury, liability, loss, cost and/or expense or damage from activities reimbursed under this program.

The representations made by applicant in this application are material terms of the agreement. The County may cancel this agreement at any time upon discovery that any of the information set forth above is inaccurate, or that any terms set forth above have been violated.

The applicant affirms that the business is in compliance with all Federal, State, and Local laws.

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* 17. Please type your name into the following text box to confirm agreement with the above statements

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