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* 1. Name of Organization/Business OR if you are an individual artist, Your Name

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* 2. Location of organization/business OR if you are an individual artist, Location of Residence/Studio?

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* 3. Category

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* 4. Current status of your business/organization

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* 5. Anticipated areas of financial impact between March 13 and April 30

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* 6. Estimated Total Financial Loss between March 13 and April 30 (in dollars)

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* 7. In case of temporary closing and/or event/program cancellation, do you anticipate an impact on staff?

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* 8. Submitted By:

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