CDBG-CV Eligibility and Interest Survey Question Title * 1. Legal Business Name Question Title * 2. Number of Employees:(Business owners should count themselves) Full Time Employees Part Time Employees Contract Employees Other Question Title * 3. Was your business open before March 1, 2020? Yes No Other (please specify) Question Title * 4. Has your business been shut down due to COVID-19 Yes No Other (please specify) Question Title * 5. Has your business revenue been reduced due to COVID-19? Yes No Other (please specify) Question Title * 6. The new CDBG-CV grant program from the Kansas Department of Commerce is available for municipalities to offer grants to area businesses with either less than 5 employees or less than 50 employees. However in order for the business to be eligible, 51% of employees must be below 80% (column C below) of the Low-to-Moderate Income limits (per HUD). Please select the number of employees that fall into the categories below so we can begin the grant eligibility process: Family Size Household Income C (80% LMI) 1 36,200 2 41,400 3 46,550 4 51,700 5 55,850 6 60,000 7 64,150 8 68,250 Example: A family of 4 that makes $47,000 for the entire household, would be counted under income BELOW C and would count towards eligibility to meet the 51% requirement. Number of Employees with HOUSEHOLD Income BELOW COLUMN C Number of Employees with HOUSEHOLD Income ABOVE COLUMN C Family Size - 1 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 1 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 1 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 2 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 2 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 2 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 3 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 3 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 3 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 4 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 4 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 4 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 5 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 5 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 5 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 6 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 6 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 6 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 7 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 7 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 7 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Family Size - 8 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 8 Number of Employees with HOUSEHOLD Income BELOW COLUMN C menu 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 25 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 Family Size - 8 Number of Employees with HOUSEHOLD Income ABOVE COLUMN C menu Question Title * 7. Does your business meet the requirement that 51% of employees fall below Column C? If no, then you do not have to complete the rest of the survey. Yes No If unsure, please contact us at TPurdon@actioncouncil.com Question Title * 8. Business Type Retail Service Based - Beauty shops, Automotive shops, Print shops, etc. Restaurant, Bar, or Hospitality Manufacturing Agriculture Healthcare Education Governmental/Public Service Non-Profit Commercial Financial Services Real Estate Other Professional Service Other (please specify) Question Title * 9. Have you received EIDL Funding: Loan Advance Loan Proceeds Yes Received Approved, but not received Applied but not approved yet Have not applied I was not eligible for funding Yes Loan Advance menu I have received funding I have not received funding but am approved Application is pending approval Application Denied I was not eligible for funding Yes Loan Proceeds menu No Received Approved, but not received Applied but not approved yet Have not applied I was not eligible for funding No Loan Advance menu I have received funding I have not received funding but am approved Application is pending approval Application Denied I was not eligible for funding No Loan Proceeds menu Question Title * 10. Have you received PPP Funding: Loan Advance Loan Proceeds Yes Received Approved, but not received Applied but not approved yet Have not applied I was not eligible for funding Yes Loan Advance menu I have received funding I have not received funding but am approved Application is pending approval Application Denied I was not eligible for funding Yes Loan Proceeds menu No Received Approved, but not received Applied but not approved yet Have not applied I was not eligible for funding No Loan Advance menu I have received funding I have not received funding but am approved Application is pending approval Application Denied I was not eligible for funding No Loan Proceeds menu Question Title * 11. Contact Email for Grant Notification Question Title * 12. Contact Phone Number Question Title * 13. What is your business street address? Question Title * 14. Business City Caney Cherryvale Coffeyville Independence Dearing Tyro Havana Montgomery County - outside city limits of any community Other (please specify) Done