2020 emergency reimbursement grant application for small
TRANSCRIPT
2020 Emergency Reimbursement Grant Application for Small Businesses
Impacted by COVID-19
The MCRA will provide up to $2,000.00 dollars reimbursement limited to eligible small businesses located within the MCRA Redevelopment District with 1-15 employees.
(Map attached or you may use website business location verification within the Margate Community Redevelopment Agency District: CRA: COVID-19 Grant Program Map).
The reimbursement grant is limited to commercial rent/mortgage and/or utility payments based upon the March 2020 billing period. Utility payments are limited to Margate Water/Sewer, FPL, Gas/Propane Utilities and Solid Waste/Recycling Services based upon the March 2020 billing period. All rent/mortgage and utility payments must be current through March 2020.
DROP OFF LOCATION: Development Services Department at 901 NW 66th Avenue, Margate FL 33063. Only Fully Completed Applications with supporting documentation as outlined below, will be reviewed.
DROP OFF HOURS: Monday-Friday between 9:00a.m. and 5:00p.m.
DEADLINE: Applications will be accepted Monday-Friday between May 11, 2020 and May 29, 2020, while funding is available. (Excludes holidays and weekends).
MCRA - CONTACT: For questions, please call or email Business Development Coordinator, Paul Robinson at (954) 954-884-3687 or [email protected] or [email protected]
BUSINESSES NOT ELIGIBLE FOR FUNDING:
• Non-Conforming Businesses • Tenants located in CRA Owned Property • Businesses that previously received CRA Grants between March 2015-March 2020 • Franchise businesses, or Businesses that are part of a chain • Mobile and Home Based Businesses • Not for Profit Businesses/Organizations • See Attachment (page 6) for Excluded Businesses
PLEASE FILL OUT THE BELOW APPLICATION (pages 2-3) AND PROVIDE DOCUMENTS LISTED ON PAGE 3.
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 1/6-05072020
2. STOREFRONT STREET ADDRESS:___________________________________________
Margate, FL., Zip Code: __________________
4. MARGATE BUSINESS TAX RECEIPT NUMBER: ________________________________
5. EMPLOYER IDENTIFICATON NUMBER / Social Security No.: _____________________ (as shown on attached W-9)
6. BUSINESS OWNER(S) HOME ADDRESS:______________________________________
AUTHORIZED BUSINESS REPRESENTATIVE NAME: ____________________________ Title: ____________________________ U.S. Veteran: Yes No Street Address:_____________________ City/State/Zip Code: _____________________ Email: ____________________________ Phone/cell: ___________________________
First Name, Middle Initial, Last Name: __________________________________________ Title: _____________________________ U.S. Veteran: Yes No Street Address: _____________________ City/State/Zip Code: _____________________ Email:_____________________________ Phone/cell: ____________________________
7. BUSINESS IN OPERATION SIX (6) MONTHS OR MORE: Yes No
8. NUMBER OF CURRENT EMPLOYEES (1-15 INCLUDING OWNER): Full Time:______ Part-time:______Independent Contractors: _________
9. NUMBER OF STAFF EMPLOYED PRIOR TO THE COVID-19 SHUT-DOWN (April 1, 2020 as provided in State of Florida Executive Order 20-91): ___________________________
10.CURRENT (through March 2020) ON COMMERCIAL RENT/MORTGAGE: Yes No (for which applying for reimbursement)
11.CURRENT (through March 2020) ON UTILITIES: Yes No (for which applying for reimbursement)
12.* OUTSTANDING CITY OF MARGATE LIENS (will be verified): Yes No
13.* OUTSTANDING CODE ENFORCEMENT VIOLATIONS (will be verified): Yes No
14. * OUTSTANDING LEGAL JUDGMENTS AGAINST THE BUSINESS (will be verified): Yes No
15.State or Federal COVID-19 funding received: $____________ Date: ________________ (for tracking purposes only)
*If yes, not eligible for grant funding.
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 2/6-05072020
GRANT REIMBURSEMENT AMOUNT REQUESTING: $_______ TOTAL Total shall not exceed $2,000.00
+ Business Rent/Mortgage: $ ________ + Margate Water/Sewer Utility: $ ________ + Florida Power and Light: $ ________ + Gas Utilities/Propane: $ ________ + Solid Waste & Recycling: $ ________
DOCUMENTS REQUIRED WITH GRANT APPLICATION: place a √ for items provided. √
1) Current Margate Business Tax Receipt
2) Bank Statement(s), credit card statement(s) and/or other documents showing business rent/mortgage and/or utilities paid in full (through March 2020)
3) Documents evidencing number of employees (Full Time, Part Time, and Independent Contractors) such as IRS Form 941, IRS Form 1096 and/or other payroll records
4) Completed IRS Form W-9
5) Deed evidencing ownership of property, and current mortgage statement, or current Business Lease or Broward County Property Appraiser’s Property Record Page
6) Utility Bill(s) for March 2020 and April 2020
7) Documentation showing proof of payment of 2019 Ad Valorem Property Taxes, if applicable
8) Document(s) indicating business owner residency in Margate (household utility bill, tax notice, household lease, etc.), if applicable
9) Document(s) indicating business owner is a United States Veteran (Florida Department of Management Certification of Veteran-owned Business Enterprise- VBE, or DD 214, DD 215 Forms, etc.), if applicable
10) Minority Business Enterprise, or Disadvantaged Business certification from Broward County, if applicable (see Appendix A, page 5)
INCOMPLETE APPLICATIONS WILL BE REJECTED! RESUBMITTALS WILL BE ACCEPTED AS NEW APPLICATIONS FOR PURPOSES OF ADMINISTERING THIS PROGRAM ON A
FIRST COME, FIRST SERVED BASIS.
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 3/6-05072020
CERTIFICATION BY APPLICANT
By signing and submitting this application, I affirm that I have received, reviewed, understand and will comply with all of the requirements of the Margate CRA 2020 Emergency Reimbursement Grant for Small Businesses in Margate CRA District Impacted by COVID-19. In addition, I affirm that I have provided a fully complete application with all of the required attachments, and that failure to provide the information received is grounds for rejection of my application. The CRA reserves the right to reject certain aspects of the application, if necessary.
In addition, I, the undersigned, being a principal of the business applying for funding assistance from the Margate Community Redevelopment Agency, hereby certify that the business represented herein is a legally operating business in the City of Margate Community Redevelopment Area.
I understand that this application is not a guarantee of assistance. Should my application be approved, I understand that I am committing to complying with all grant requirements. I agree to maintain a valid Margate business tax receipt at all times.
Please note that the Margate CRA is a public agency. As such, the MCRA is governed by Section 119.07, et.seq., Florida Statutes, the “Florida Public Records Law.” Any documents provided by the Applicant may be subject to production by the MCRA, upon receipt of a public records request, subject to any exemptions provided by Florida Law. If you qualify for an exemption to public records disclosure you must advise the MCRA and provide proof of your exemption.
I understand that I should consult with my tax advisor on any potential tax obligations resulting from the receipt of the grant funds.
If the MCRA becomes aware or obtains knowledge that any information provided by the Applicant is false, the MCRA shall pursue all legal remedies to obtain reimbursement of the funds provided.
The MCRA reserves the right to make any changes to the Grant Program at any time and to request additional information needed to confirm the grant application.
Once a completed application is submitted, it may take up to 3 weeks for reimbursement checks to be mailed. Reimbursement checks will be mailed to the address listed on the W-9 submitted with application.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN CONJUNCTION WITH THIS APPLICATION IS TRUE AND ACCURATE:
BY: _______________________ __________________________________ Date: ___________ Print Name Signature
To Be Completed by MCRA Staff Date/Time Received by MCRA Staff: _____________________________________________________ Received by: ________________________________________________________________________ Reviewed by: ________________________________________________________________________ Application approved: _________________________________________________________________ Yes No Date:___________ Print Name:__________________ Signature:________________
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 4/6-05072020
APPENDIX A
I certify that I am a business that is 51% owned, controlled and managed by socially and economically disadvantaged U.S. citizen or legal resident who belongs to one or more of the following categories:
African-American / Black Hispanic Subcontinent Asian Asian-Pacific Native Woman
I HEREBY CERTIFY THAT I MEET THE ABOVE MINIORITY DESIGNATION.
Print Name: ____________________ Signature: _________________________
Excluded Businesses for COVID-19 CRA Emergency Grant
• Auto Sales-Repairs, Stereo/Tint • Auto Body Shops • Bars & Night Clubs • Check Cashing • Churches • Coin Laundry • Credit Repair • Funeral Homes • Gas Stations • Liquor stores • Massage Establishments • Medical Facilities • Motels • Pawnshops/Jewelry & Loan • Storage Warehouse • Retirement Home • Towing Company • Treatment Centers • Vaping/Tobacco Establishments • Vehicle Transportation
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 6/6-05072020
1•••1 .......
NW 34 ST
TA N
CO NF
ET TI
L N
PARADE PL
FIESTA WAY
MERRI CK TER
NW 32 CT MARION AVE
SW
C
L
I JAMES ST VOCNW 31 ST C EA APMON N
B L V D
PA LM
P L
NW 72
AV E C D COURTYARD NW 30 CT NW 30 CT
CA RY
AN LN
R R
E PL
NW 71
N G S I
S NW 53 TER
SU NS
A
2I W 30 CT 9N
S P R CC T A NW 29 CT RLP I OS
DR
N
L
A
NW 29 CT CELEBRATIR 65NW 29 ST E
CR ES TNW 29 CT W 4N 6 NW 29 CT C
TER NW 69 TER
75 AV
NW 52I VA AL
4D 6 NW 29 ST R NW WNNW 29 ST R NW 29 ST N
NW 75 TER
N 8 32 6W 8 L
NW 28 CT N W NW 28 CT
D2
S
PINEWALK DR S
NW 27 ST
NW 74 AVE E NW 28 ST NW 28 ST NW 28 S T NW 27 CT
NW 18 ST
NW 27 ST
NW 27 CT ST 9 NW 27 ST NW 27 ST 2 NW 27 ST
NW 69 AVE
N W NW 27 ST NW 27 ST NW 27 ST NW 26 CT NW 70AVE NW
6 8 A
NW 64
T ER
0 A VE
N T W
7 S NW6
NW 68 TER
29 T 7
NW 72 AVE
W 9 AVE N NW 25 ST E T R 4 S W 2
N
COPA NS RD NW 24 ST
S HEMIN GWAY CIR
NW 23 ST
R O Y A L P A L M B L V D
NW 23 ST NW 23 ST
VE R
E R
A
Y NW
NW 76
TE R
NW 8
NW 76
AV E
NW 79
AV E
NW 21 CT NW 20 CT NW 21 ST NW 20 ST
NW 66 AVE
NW 20 ST
NW 19 CT
NW 65AVE
NW 19 ST
NW 19 ST
NW 11 ST
NW 18 CT NW 19 CT NW 19 ST NW 19 ST CYPRESS DR NW 17 ST
SE VI
LL E
AY
NW 18 PL NW 18 CT NW 18 CT NW 18 PL
NW 18 ST NW 18 ST NW 16 ST NW 17 CT NW 17 CT
NW 6
5 T ER
NW 17 ST NW 17TH ST NW 17 ST NW 17 ST NW 17 ST
NW 6
NW 63
AV E
NW 16 ST
NW 15 ST NW 15 ST NW 15 ST
NW 16 ST NW 15 CT NW 15 CNW 14 CT
NW 14 ST
NW 13 ST
NW 6
N
NWNW 14 CT NW 14 ST 15NW 14 ST ST NW 14 CT
NW 62
TE R
NW 6
AY
E V A62R D NWRE P K Y C R EE K C O C O N U T NW 12 ST VIR R W ETR 8D 5
CO UN
TR Y
CL UB
NW 72
T ER
E DR
NW 8
GATE BL
NW 74
AV E
NW 73
T AWC NW 9 ST RR NNW 9 CT KIC DF
NW 73
AV E R LNW 9 ST NW 9 ST NW 11 ST O
NW 9 ST
NW 73
T ER
NW 69
T ER
NW 80
T ER
LA KE
SI DE
D R
NW 7 PL
NW 72
TE R NW 9 ST NW 7 CT NW 7 CT
NW 73
NW 8 CT NW 6 CT
NW 1 CT
9 A VE
NW 6 CT STRAWBERRY LN NW 6 CT NW 8 ST
NW 6
NW 6
5 T ER
NW 5 CT NW 5 CT NW 5 CT NW 5 CT
NW 8
LAKEWOOD C
NW 6
W O O
R O C K I S L A N D
NW 4 ST RD
LA KE
W OO
D PA
NW 7
OD CIR E
N HEMINGWAY CIR
NW 6
NW 1 ST
SW 5
6 A VE
N CO N CORTEZ DR PARKWAY DR N RSW 1 ST TE
SW 6
SW 6
SW 7
NDIAL C
DI AL
SW 67 AVE
SW 6
SW 4 ST
CURRY CIR MONTE CARLO PL SW 4 ST SW 4 ST S C S CORTEZ DR
PR IN
CE SS
D R
SW 5 ST 6 SW 4 PL 8 TER
T SW 5 ST SW 5 ST S
SW 6
SW 6
7 R D
SW 7 ST
SW 7 PL
SW 50
W AY
SW 5
SW 5
SW 11 CIR SW 11 ST
11 PL
AL
C RO
LP KY
SW 3 ST
SW 4 PL
5 EMPLOYER IDENTIFICATON NUMBER Social Security No:
6 BUSINESS OWNERS HOME ADDRESS:
AUTHORIZED BUSINESS REPRESENTATIVE NAME:
Title_2:
15State or Federal COVID19 funding received:
Date:
The MCRA will provide up to $2,000.00 dollars reimbursement limited to eligible small businesses located within the MCRA Redevelopment District with 1-15 employees.
(Map attached or you may use website business location verification within the Margate Community Redevelopment Agency District: CRA: COVID-19 Grant Program Map).
The reimbursement grant is limited to commercial rent/mortgage and/or utility payments based upon the March 2020 billing period. Utility payments are limited to Margate Water/Sewer, FPL, Gas/Propane Utilities and Solid Waste/Recycling Services based upon the March 2020 billing period. All rent/mortgage and utility payments must be current through March 2020.
DROP OFF LOCATION: Development Services Department at 901 NW 66th Avenue, Margate FL 33063. Only Fully Completed Applications with supporting documentation as outlined below, will be reviewed.
DROP OFF HOURS: Monday-Friday between 9:00a.m. and 5:00p.m.
DEADLINE: Applications will be accepted Monday-Friday between May 11, 2020 and May 29, 2020, while funding is available. (Excludes holidays and weekends).
MCRA - CONTACT: For questions, please call or email Business Development Coordinator, Paul Robinson at (954) 954-884-3687 or [email protected] or [email protected]
BUSINESSES NOT ELIGIBLE FOR FUNDING:
• Non-Conforming Businesses • Tenants located in CRA Owned Property • Businesses that previously received CRA Grants between March 2015-March 2020 • Franchise businesses, or Businesses that are part of a chain • Mobile and Home Based Businesses • Not for Profit Businesses/Organizations • See Attachment (page 6) for Excluded Businesses
PLEASE FILL OUT THE BELOW APPLICATION (pages 2-3) AND PROVIDE DOCUMENTS LISTED ON PAGE 3.
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 1/6-05072020
2. STOREFRONT STREET ADDRESS:___________________________________________
Margate, FL., Zip Code: __________________
4. MARGATE BUSINESS TAX RECEIPT NUMBER: ________________________________
5. EMPLOYER IDENTIFICATON NUMBER / Social Security No.: _____________________ (as shown on attached W-9)
6. BUSINESS OWNER(S) HOME ADDRESS:______________________________________
AUTHORIZED BUSINESS REPRESENTATIVE NAME: ____________________________ Title: ____________________________ U.S. Veteran: Yes No Street Address:_____________________ City/State/Zip Code: _____________________ Email: ____________________________ Phone/cell: ___________________________
First Name, Middle Initial, Last Name: __________________________________________ Title: _____________________________ U.S. Veteran: Yes No Street Address: _____________________ City/State/Zip Code: _____________________ Email:_____________________________ Phone/cell: ____________________________
7. BUSINESS IN OPERATION SIX (6) MONTHS OR MORE: Yes No
8. NUMBER OF CURRENT EMPLOYEES (1-15 INCLUDING OWNER): Full Time:______ Part-time:______Independent Contractors: _________
9. NUMBER OF STAFF EMPLOYED PRIOR TO THE COVID-19 SHUT-DOWN (April 1, 2020 as provided in State of Florida Executive Order 20-91): ___________________________
10.CURRENT (through March 2020) ON COMMERCIAL RENT/MORTGAGE: Yes No (for which applying for reimbursement)
11.CURRENT (through March 2020) ON UTILITIES: Yes No (for which applying for reimbursement)
12.* OUTSTANDING CITY OF MARGATE LIENS (will be verified): Yes No
13.* OUTSTANDING CODE ENFORCEMENT VIOLATIONS (will be verified): Yes No
14. * OUTSTANDING LEGAL JUDGMENTS AGAINST THE BUSINESS (will be verified): Yes No
15.State or Federal COVID-19 funding received: $____________ Date: ________________ (for tracking purposes only)
*If yes, not eligible for grant funding.
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 2/6-05072020
GRANT REIMBURSEMENT AMOUNT REQUESTING: $_______ TOTAL Total shall not exceed $2,000.00
+ Business Rent/Mortgage: $ ________ + Margate Water/Sewer Utility: $ ________ + Florida Power and Light: $ ________ + Gas Utilities/Propane: $ ________ + Solid Waste & Recycling: $ ________
DOCUMENTS REQUIRED WITH GRANT APPLICATION: place a √ for items provided. √
1) Current Margate Business Tax Receipt
2) Bank Statement(s), credit card statement(s) and/or other documents showing business rent/mortgage and/or utilities paid in full (through March 2020)
3) Documents evidencing number of employees (Full Time, Part Time, and Independent Contractors) such as IRS Form 941, IRS Form 1096 and/or other payroll records
4) Completed IRS Form W-9
5) Deed evidencing ownership of property, and current mortgage statement, or current Business Lease or Broward County Property Appraiser’s Property Record Page
6) Utility Bill(s) for March 2020 and April 2020
7) Documentation showing proof of payment of 2019 Ad Valorem Property Taxes, if applicable
8) Document(s) indicating business owner residency in Margate (household utility bill, tax notice, household lease, etc.), if applicable
9) Document(s) indicating business owner is a United States Veteran (Florida Department of Management Certification of Veteran-owned Business Enterprise- VBE, or DD 214, DD 215 Forms, etc.), if applicable
10) Minority Business Enterprise, or Disadvantaged Business certification from Broward County, if applicable (see Appendix A, page 5)
INCOMPLETE APPLICATIONS WILL BE REJECTED! RESUBMITTALS WILL BE ACCEPTED AS NEW APPLICATIONS FOR PURPOSES OF ADMINISTERING THIS PROGRAM ON A
FIRST COME, FIRST SERVED BASIS.
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 3/6-05072020
CERTIFICATION BY APPLICANT
By signing and submitting this application, I affirm that I have received, reviewed, understand and will comply with all of the requirements of the Margate CRA 2020 Emergency Reimbursement Grant for Small Businesses in Margate CRA District Impacted by COVID-19. In addition, I affirm that I have provided a fully complete application with all of the required attachments, and that failure to provide the information received is grounds for rejection of my application. The CRA reserves the right to reject certain aspects of the application, if necessary.
In addition, I, the undersigned, being a principal of the business applying for funding assistance from the Margate Community Redevelopment Agency, hereby certify that the business represented herein is a legally operating business in the City of Margate Community Redevelopment Area.
I understand that this application is not a guarantee of assistance. Should my application be approved, I understand that I am committing to complying with all grant requirements. I agree to maintain a valid Margate business tax receipt at all times.
Please note that the Margate CRA is a public agency. As such, the MCRA is governed by Section 119.07, et.seq., Florida Statutes, the “Florida Public Records Law.” Any documents provided by the Applicant may be subject to production by the MCRA, upon receipt of a public records request, subject to any exemptions provided by Florida Law. If you qualify for an exemption to public records disclosure you must advise the MCRA and provide proof of your exemption.
I understand that I should consult with my tax advisor on any potential tax obligations resulting from the receipt of the grant funds.
If the MCRA becomes aware or obtains knowledge that any information provided by the Applicant is false, the MCRA shall pursue all legal remedies to obtain reimbursement of the funds provided.
The MCRA reserves the right to make any changes to the Grant Program at any time and to request additional information needed to confirm the grant application.
Once a completed application is submitted, it may take up to 3 weeks for reimbursement checks to be mailed. Reimbursement checks will be mailed to the address listed on the W-9 submitted with application.
I HEREBY CERTIFY THAT ALL INFORMATION PROVIDED IN CONJUNCTION WITH THIS APPLICATION IS TRUE AND ACCURATE:
BY: _______________________ __________________________________ Date: ___________ Print Name Signature
To Be Completed by MCRA Staff Date/Time Received by MCRA Staff: _____________________________________________________ Received by: ________________________________________________________________________ Reviewed by: ________________________________________________________________________ Application approved: _________________________________________________________________ Yes No Date:___________ Print Name:__________________ Signature:________________
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 4/6-05072020
APPENDIX A
I certify that I am a business that is 51% owned, controlled and managed by socially and economically disadvantaged U.S. citizen or legal resident who belongs to one or more of the following categories:
African-American / Black Hispanic Subcontinent Asian Asian-Pacific Native Woman
I HEREBY CERTIFY THAT I MEET THE ABOVE MINIORITY DESIGNATION.
Print Name: ____________________ Signature: _________________________
Excluded Businesses for COVID-19 CRA Emergency Grant
• Auto Sales-Repairs, Stereo/Tint • Auto Body Shops • Bars & Night Clubs • Check Cashing • Churches • Coin Laundry • Credit Repair • Funeral Homes • Gas Stations • Liquor stores • Massage Establishments • Medical Facilities • Motels • Pawnshops/Jewelry & Loan • Storage Warehouse • Retirement Home • Towing Company • Treatment Centers • Vaping/Tobacco Establishments • Vehicle Transportation
MCRA Small Business Grant Emergency Reimbursement COVID-19 page 6/6-05072020
1•••1 .......
NW 34 ST
TA N
CO NF
ET TI
L N
PARADE PL
FIESTA WAY
MERRI CK TER
NW 32 CT MARION AVE
SW
C
L
I JAMES ST VOCNW 31 ST C EA APMON N
B L V D
PA LM
P L
NW 72
AV E C D COURTYARD NW 30 CT NW 30 CT
CA RY
AN LN
R R
E PL
NW 71
N G S I
S NW 53 TER
SU NS
A
2I W 30 CT 9N
S P R CC T A NW 29 CT RLP I OS
DR
N
L
A
NW 29 CT CELEBRATIR 65NW 29 ST E
CR ES TNW 29 CT W 4N 6 NW 29 CT C
TER NW 69 TER
75 AV
NW 52I VA AL
4D 6 NW 29 ST R NW WNNW 29 ST R NW 29 ST N
NW 75 TER
N 8 32 6W 8 L
NW 28 CT N W NW 28 CT
D2
S
PINEWALK DR S
NW 27 ST
NW 74 AVE E NW 28 ST NW 28 ST NW 28 S T NW 27 CT
NW 18 ST
NW 27 ST
NW 27 CT ST 9 NW 27 ST NW 27 ST 2 NW 27 ST
NW 69 AVE
N W NW 27 ST NW 27 ST NW 27 ST NW 26 CT NW 70AVE NW
6 8 A
NW 64
T ER
0 A VE
N T W
7 S NW6
NW 68 TER
29 T 7
NW 72 AVE
W 9 AVE N NW 25 ST E T R 4 S W 2
N
COPA NS RD NW 24 ST
S HEMIN GWAY CIR
NW 23 ST
R O Y A L P A L M B L V D
NW 23 ST NW 23 ST
VE R
E R
A
Y NW
NW 76
TE R
NW 8
NW 76
AV E
NW 79
AV E
NW 21 CT NW 20 CT NW 21 ST NW 20 ST
NW 66 AVE
NW 20 ST
NW 19 CT
NW 65AVE
NW 19 ST
NW 19 ST
NW 11 ST
NW 18 CT NW 19 CT NW 19 ST NW 19 ST CYPRESS DR NW 17 ST
SE VI
LL E
AY
NW 18 PL NW 18 CT NW 18 CT NW 18 PL
NW 18 ST NW 18 ST NW 16 ST NW 17 CT NW 17 CT
NW 6
5 T ER
NW 17 ST NW 17TH ST NW 17 ST NW 17 ST NW 17 ST
NW 6
NW 63
AV E
NW 16 ST
NW 15 ST NW 15 ST NW 15 ST
NW 16 ST NW 15 CT NW 15 CNW 14 CT
NW 14 ST
NW 13 ST
NW 6
N
NWNW 14 CT NW 14 ST 15NW 14 ST ST NW 14 CT
NW 62
TE R
NW 6
AY
E V A62R D NWRE P K Y C R EE K C O C O N U T NW 12 ST VIR R W ETR 8D 5
CO UN
TR Y
CL UB
NW 72
T ER
E DR
NW 8
GATE BL
NW 74
AV E
NW 73
T AWC NW 9 ST RR NNW 9 CT KIC DF
NW 73
AV E R LNW 9 ST NW 9 ST NW 11 ST O
NW 9 ST
NW 73
T ER
NW 69
T ER
NW 80
T ER
LA KE
SI DE
D R
NW 7 PL
NW 72
TE R NW 9 ST NW 7 CT NW 7 CT
NW 73
NW 8 CT NW 6 CT
NW 1 CT
9 A VE
NW 6 CT STRAWBERRY LN NW 6 CT NW 8 ST
NW 6
NW 6
5 T ER
NW 5 CT NW 5 CT NW 5 CT NW 5 CT
NW 8
LAKEWOOD C
NW 6
W O O
R O C K I S L A N D
NW 4 ST RD
LA KE
W OO
D PA
NW 7
OD CIR E
N HEMINGWAY CIR
NW 6
NW 1 ST
SW 5
6 A VE
N CO N CORTEZ DR PARKWAY DR N RSW 1 ST TE
SW 6
SW 6
SW 7
NDIAL C
DI AL
SW 67 AVE
SW 6
SW 4 ST
CURRY CIR MONTE CARLO PL SW 4 ST SW 4 ST S C S CORTEZ DR
PR IN
CE SS
D R
SW 5 ST 6 SW 4 PL 8 TER
T SW 5 ST SW 5 ST S
SW 6
SW 6
7 R D
SW 7 ST
SW 7 PL
SW 50
W AY
SW 5
SW 5
SW 11 CIR SW 11 ST
11 PL
AL
C RO
LP KY
SW 3 ST
SW 4 PL
5 EMPLOYER IDENTIFICATON NUMBER Social Security No:
6 BUSINESS OWNERS HOME ADDRESS:
AUTHORIZED BUSINESS REPRESENTATIVE NAME:
Title_2:
15State or Federal COVID19 funding received:
Date: