Application portal closes at noon, Dec. 4


This portal DOES NOT allow you to save your work and return at a later time. Before starting the application, make sure you have the required documents and information available to you. Responses cannot be edited once the form is submitted.

All documentation must be formatted as a PDF, DOC, DOCX, PNG, JPG or JPEG. Excel files are not supported and must be converted to one of the listed file types. It is also important to rename the files to include your company name. It is anticipated that numerous applications will be received. Processing them will be greatly expediated by having the uploads clearly connected to each applicant.

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* 1. Entity Information

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* 2. Main Contact
This person will serve as the authorized signature for the entity.

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* 3. If the entity uses a different name in the marketplace than the one listed above, list any additional names you use here.

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* 4. Applicant Type

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* 5. What is the entity's FEIN, EIN or Taxpayer ID number? 
Include hyphens in your answer.
  • Example format for Tax Payer IDs: XXX-XX-XXXX 
  • Example format for FEINs:XX-XXXXXXX
  • Example format for EINs: XX-XXXXXXX

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* 6. Is this a homebased or mobile operation?

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* 7. Is your entity an independent organization or part of a franchise?

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* 8. Where does your ownership live?

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* 16. If awarded, what expenses would you cover with this grant?

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* 17. Please describe the negative impact COVID-19 has created.  Provide information on how you have changed operations and incurred new expenses.
Response limited to 500 to 1,000 characters.

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* 18. The Applicant must certify to each of the statements below by checking the boxes below:

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* 19. By completing this application, the Applicant, individually and on behalf of the Applicant, authorizes and consents to the disclosure, review, and storage of information by Miami County, Kansas, and any of their affiliates of any and all information and documents submitted in connection with this Application. The Applicant understands and acknowledges that the funding for the program is limited and that the Applicant is not legally entitled to receive a grant from the Miami County CARES Small Business Grant Program. In this regard, the Applicant agrees that Miami County, Kansas, or any of their affiliates shall not be liable to the Applicant, or any third party affiliated with the Applicant, and hereby releases Miami County from, any and all costs, expenses, damages, claims, or loss of any kind as may be incurred in connection with the grant requested in this application or for anything they may do or refrain from doing, including, without limitation, any action or inaction relating to grant application requirements, grant criteria, application review and processing, grant approval or disapproval, grant payment amount, and all communications relating to any of the foregoing requirements, processes, or actions.

The Applicant must certify to each of the statements below by checking the box below:

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* 20. By submitting this application, you certify that you are authorized to apply for grant funds on behalf of the business identified. You also certify that the information provided is true and correct to the best of your knowledge. Falsification of information could result in the immediate repayment of grant funds with the possibility of other legal action.

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* 21. Upload a Profit and Loss Report for March 1, 2019 through Aug. 31, 2019.
If your entity was not open during that period in 2019, provide a Profit and Loss Report for the period it was open prior to March 1, 2020.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.
Choose File

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* 22. Upload a Profit and Loss Report for March 1, 2020 through Aug. 31, 2020.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.
Choose File

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* 23. Upload a completed W-9.

PDF, DOC, DOCX, PNG, JPG, JPEG file types only.
Choose File

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