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* 1. Legal Business Name

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* 2. Primary Contact Person

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* 3. DUNS NUMBER

Go back to step 2 on the website and complete your DUNS number request if you do not have your DUNS number yet.  Your application will be rejected automatically if this is not completed.

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* 4. Where is your business located?  

NOTE: At this time, only businesses located in the County AND INCLUDING CANEY ARE ELIGIBLE.  Grants for businesses inside the city limits of Coffeyville, Cherryvale, and Independence HAVE CLOSED.

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* 5. Business Type

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* 6. Business Structure

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* 7. Does the applying business have a related operating or holding company?

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* 8. Date your business was established:

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* 9. Was your business established and open prior to March 1, 2020?

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* 10. Gross Revenue/Sales from 2019 (Using March - October):

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* 11. Gross Revenue/Sales for 2020 (Using March - October):

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* 12. Based on the difference between 2020 and 2019, have you had a loss in revenue in 2020?

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* 13. What was your 2019 Cost of Goods Sold or Expenses (Using March - October)

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* 14. What was your 2020 Cost of Goods Sold or Expenses (Using March - October)

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* 15. Was your business shut down due to COVID-19?

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* 16. What is your annual payroll total? (All employees)

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* 17. Have you received funds from the following programs during the COVID-19 disaster:

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* 18. Did you receive Payroll Protection Program (PPP) Funding?

If so, CDBG-CV funds can ONLY be used for inventory.

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* 19. Number of Employees:
FTE’s (Full-Time Equivalent) will be figured by the following formula by the Department.

40 Hour Week
0 - 5 hours             0 Person
6 - 15 hours           1/4 Time Person
16 - 25 hours         1/2 Time Person
26 - 35 hours         3/4 Time Person
36 - 40 hours         Full-Time Employee

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* 20. Per the grant requirements, 51% of employees working for the business that are at risk (Retained) of losing their jobs must be LMI Qualified (meaning their total household income is below Column C below) for the business to be eligible for the job retention grant. How many employees do you have that ARE AT RISK (retained) of losing their jobs without this funding?

For example if you have 30 employees, 20 are not at risk of losing their jobs, but 10 will only be retained unless the business receives some sort of funding. Only the 10 employees to be retained must complete the LMI certification sheet. 51% of the 10 employees (6+) must be qualified as an LMI employee for the business to be eligible. 

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* 21. A key requirement for business eligibility is that 51% of RETAINED employees have a TOTAL HOUSEHOLD INCOME (based on adjusted gross income of the total household) that is categorized as Low to Moderate income. Therefore in order for the business to be eligible, 51% of RETAINED employees must be below the corresponding row in Column C of the Low-to-Moderate Income limits (per HUD) to count as an LMI qualified employee. 

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 as a qualifying employee as they are under "Household Income C (80%)" 

  Number of Employees with HOUSEHOLD Income BELOW COLUMN C Number of Employees with HOUSEHOLD Income ABOVE COLUMN C
Family Size  - 1
Family Size - 2
Family Size - 3
Family Size - 4
Family Size - 5
Family Size - 6
Family Size - 7
Family Size - 8

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* 22. Does your business meet the requirement that 51% of retained employees fall below Column C?

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* 23. Will these jobs be retained as a result of the funds?

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* 24. Types of Jobs Retained 

(Provide the number of jobs retained for each category below:)

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* 25. Average Wages of Retained employees

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* 26. Of jobs retained, number of jobs with employer sponsored health benefits:

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* 27. What is your total working capital need to retain employees? Grant is for $2,000 per full time employee (including owners) and $1,000 per part time employee.

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* 28. What type of working capital will the funds be used for (e.g. Utilities, payroll, inventory, supplies, PPE, etc.)

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* 29. Please provide a short description of how COVID-19 is negatively impacting the business (e.g. weekly sales average drop for restaurants, occupancy rate drop for long term healthcare facilities, etc).

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* 30. Describe how the use of the CDBG loan fund enhances the ability of this business to survive.

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* 31. Please provide a description of the services provided by your business:

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* 32. Does the business owner have a tax liability in arrears with the Kansas Department of Revenue of the IRS?

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* 33. Please provide contact information of the bank that the business currently works with for financing or checking:

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* 34. List any resource partners that have helped you deal with business issues created during the COVID-19 pandemic.

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* 35. Voluntary Demographics: 
Gender

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* 36. Voluntary Demographics 
VETERAN

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* 37. VOLUNTARY DEMOGRAPHICS

Race/Ethnicity

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* 38. The official State of Kansas LMI Certification form is required in order to complete this application.  Please download and complete the Employee Certification form for each RETAINED EMPLOYEE.  Employees can submit this confidentially to admin@actioncouncil.com.

If the employer does not count all employees as retained employees, we will also require a letter from the business owner certifying which employees are not at risk, and which employees will be categorized as "at risk - RETAINED" employees.  

REQUIRED FORM
 Employee Certification Form

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* 39. Funds from this grant can only be used for the following purposes:
  • Inventory
  • Payroll
  • Wages
  • Utilities
  • Everyday expenses
It can not be used to pay off existing debt. BUSINESSES MUST SUBMIT RECEIPTS FOR THESE ITEMS BEFORE FUNDING WILL BE APPROVED, IN THE AMOUNT OF YOUR POTENTIAL GRANT AWARD ($2,000/full time employee, and $1,000 per part-time employee)

If a business received PPP funding, only inventory will be an allowed expense for CDBG-CV grant funding.

 
 100% of survey complete.

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