1

SMALL BUSINESS STABILIZATION

GRANT APPLICATION Things to consider before you apply

1. Please read the entire description and criteria for the grant.

2. You must meet the criteria or your application will be rejected

3. Business Owner Must Be Resident of the City of Memphis, no exceptions, at this time

a. If you are a Shelby County but not City of Memphis or resident of the State of

MS you may contact your local government officials for possible resources

4. You must declare subject to perjury that you watched the 3 videos on the website

5. Tax Returns Required. You must submit your signed tax returns and the 4506-T

6. Submit in ONE EMAIL full application packet including a scanned pdf of all required

documents not screenshots/pictures your application will be rejected

7. Do not send emails multiple emails of documents or your application will be rejected

8. You must answer all required questions or your application will be rejected

9. You will not be advised of your eligibility. You must read the criteria and then apply.

10. Calling or emailing will not change the requirements. You must meet the criteria and

you must apply.

Please be patient. We are here to help you. #WEMEANBUSINESS

2

SMALL BUSINESS STABILIZATION GRANT APPLICATION

Email Completed Application & All Additional Required Documents to:

OBDCgrants@memphistn.gov or Call 901-636-9300 for Assistance to be connected to Business Navigator

SECTION I. GENERAL INFORMATION

Date of Application:

Full Legal Name/Title:

Primary Residence (No P.O. Box):

City County State Zip

(Must provide proof of residence.)

Legal Name of Company:

Phone #:

Other Phone #: Email:

Street address of firm (No P.O. Box):

City County State Zip

Are you located within a Memphis 3.0 anchored land use area?: Yes No Not Sure

This company was established on: / /

Number of employees: Full-time Part-time Seasonal Total:

(Provide a list of employees, their job titles, and dates of employment with your application).

2019 Gross Receipts: Are City/County taxes current? Yes No

NAICS Code:

3

SMALL BUSINESS STABILIZATION GRANT APPLICATION

SECTION I. GENERAL INFORMATION CONT…

Are you a business that supports anchor industries according to the Greater Memphis Chamber

website?: https://memphischamber.com/select-memphis/target-industries/ Yes No

If yes, what industry. Please be exact:

Are you a certified disadvantaged, minority or woman owned business?: Yes No

❖ Must provide proof of certification certificate/letter

Grant Amount Requested:

I, the undersigned, certify, to the best of my knowledge, under perjury and penalty that:

1. I am the owner of ___________________________________________________ ("Business");

2. The Business has had a significant negative economic impact due to the Covid-19 pandemic;

3. The Business, or any owners on behalf of the Business, have not received any other grant from the City of Memphis or any other government or private source related to the COVID-19 pandemic that has not been disclosed;

4. If a grant is awarded to the Business, the proceeds of that grant will be used as outlined in the program’s eligible fund uses. If not, said funds shall be returned to the City of Memphis; and

5. I understand and acknowledge that any material or false statement or omission made in connection with this application is sufficient cause for denial and may subject the person and/or entity making the false statement to any and all civil and criminal penalties available pursuant to applicable federal and state law.

Business Name Business Owner (Signature) Business Owner Name (Print) Date

4

SMALL BUSINESS STABILIZATION GRANT APPLICATION

Section II. DUPLICATION OF BENEFITS DECLARATION

This section identifies any sources of funds that the business has received as a result of the COVID-19 pandemic including insurance. Sources of funds include but are not limited to: Federal, state and local loan/grant programs, private or bank loans, nonprofit donations or loans. Please indicate below the

amount allocated to your business from any and all funding sources not.

This declaration must be completed by all businesses that have applied for and/or received any assistance from the Small Business Stabilization Grant Program being offered by the City of Memphis’s, Office of Business Diversity & Compliance (“OBDC”). The information within this declaration will provide OBDC with vital information for processing the application required by the Stafford Act Section 312 on Duplication of Benefits.

Under penalty of perjury and penalty of violation of Federal and State laws applicable to the subject application for and receipt of a grant under the Small Business Stabilization Fund, the undersigned

makes the following representations and avers their truth and accuracy:

A. I hereby state that I am the owner of __________________________ __(the “Applicant”) and am duly authorized by the Applicant to make the certifications contained in this Declaration

on behalf of the Applicant.

B. I received or applied for funding from the COVID-19 business or economic assistance program(s)** listed in this section below and/or filed a claim with or received payment from an insurance company listed in this section below. State “NONE” if not applicable:

1. 4.

2. 5.

3. 6.

**Please see possible funders listed below for examples of the types of programs referenced in this

question. Please note that this is not an all-inclusive list.

C. I hereby state and certify to the United States Department of Housing and Urban Development and to the City of Memphis’s, Office of Business Diversity & Compliance as follows (please check one blank):

• On any date on or after March 24, 2020, property, flood, and/or wind, economic injury, business interruption or any other kind of insurance WAS carried and in force for Applicant.

• On any date on or after March 24, 2020, NO property, flood, and/or wind, economic injury, business interruption or any other kind of insurance was carried and in force for Applicant. If Applicant carried insurance, fill in the information requested below using the insurance information in effect at the time of damage to the Property due to the COVID-19 pandemic, on or after March 24, 2020.

5

D. SMALL BUSINESS STABILIZATION GRANT APPLICATION

Section II. DUPLICATION OF BENEFITS DECLARATION cont…

D. On the _____ day of _____________, 2020, I viewed all three (3) REQUIRED Financial Literacy Tips videos in their entirety from the website hosted by the City of Memphis’ Office of Business Diversity & Compliance.

By signing this Declaration, Applicant(s) acknowledge and understand that Title 18 United States Code Section 1001: (1) makes it a violation of federal law for a person to knowingly and willfully (a) falsify, conceal, or cover up a material fact; (b) make any materially false, fictitious, or fraudulent statement or representation; OR (c) make or use any false writing or document knowing it contains a materially false, fictitious, or fraudulent statement or representation, to any branch of the United States Government; and (2) requires a fine, imprisonment for not more than five (5) years, or both, which may be ruled a felony, for any violation of such Section.

Dated this the _____ day of _____________, 2020.

Business Owner Signature Business Owner Name (Print)

**List of possible “relief funds” received to be used as a reference for the Duplication of Benefits Declaration:

• EDGE Neighborhood Emergency Economic Development (NEED) Grant

• Shelby County Our Beautiful Comeback Grants

• City of Memphis COVID-19 Relief Grants - Community Development Block Grant Program

• City of Memphis Micro-Loan Program Economic Hardship Emergency Loan

• Downtown Business Continuity Forgivable Loan Program

• MMDC Small Business Emergency Assistance Fund

• River City Capital (Community LIFT) Recovery Loan

• Pathway Lending

• Grantspace

• Tennessee Business Relief Program

• SBA COVID-19 – Paycheck Protection Program (PPP); Economic Injury Disaster Loan(EIDL)

6

SMALL BUSINESS STABILIZATION GRANT APPLICATION

Section III. COVID-19 IMPACT & USE OF FUNDS QUESTIONNAIRE

Please answer the following questions, where applicable. Please provide documentation, if available,

with your application to support your responses below.

1. How has the impact of Covid-19 impacted your number of employees and/or payroll reductions?

Please be specific with numbers.

2. Has Covid-19 caused your sales and revenue to decrease? If so, how? Please be specific with

dollar figures.

3. Has Covid-19 caused supplier or customer interruptions for your business? Please explain.

7

SMALL BUSINESS STABILIZATION GRANT APPLICATION

Section III. COVID-19 IMPACT & USE OF FUNDS QUESTIONNAIRE cont…

4. How has Covid-19 impacted your ability to satisfy debts and obligations? Please be specific and

include a listing of those debts and obligations w/dollar amounts if applicable.

5. How will you use the City of Memphis Stabilization Grant Funds and to help your business

recovery?

8

SMALL BUSINESS STABILIZATION GRANT CHECKLIST

Checklist for City of Memphis Sustainability Grant Program:

□ Completed and signed application

□ Duplication of Benefits Declaration

□ Impact Statement & Use of Funds Questionnaire and all supporting

documentation

Documentation in addition to Application

□ Current TN Business License (if applicable)

□ Copy of Lease Agreement/ Commercial Mortgage Documents or other

proof of residence

□ Valid TN Driver’s License or Immigration documents such as Green Card

□ TN Legal Organizational Documents (Corporation, LLC, Partnership,

etc.)

□ 2019 Principal Tax Return (Tax returns of all majority owners) 2018 if not

filed

□ 2019 Business Tax Return

□ Signed 4506-T

9

SMALL BUSINESS STABILIZATION GRANT CHECKLIST

The following types of business are ineligible:

• Liquor and tobacco stores

• Adult entertainment and product stores

• Pawnshop, Payday loans, Title loan establishments

• Car dealerships

• Mini-storage

• Gas Stations

• Financial businesses primarily engaged in lending

• Real estate development or rental businesses

• Insurance companies

• Private clubs

• Retail clothing stores, Major operators such as Best Buy, Walmart etc.

• Non-profit agencies

• Churches and religious institutions, and government entities

• Others at the discretion of the City of Memphis OBDC staff

I am the owner of: Business Name: Business Owner Name Print: Date: 1: 4: 2: 5: 3: 6: Tips videos in their entirety from the website hosted by the City of Memphis Office of Business: 2020 I viewed all three 3 REQUIRED Financial Literacy: day of: 2020: Business Owner Name Print_2: Text1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: Text11: Text12: Text13: Text14: Text15: Text16: Check Box17: OffCheck Box18: OffCheck Box19: OffText20: Text21: Text22: Text23: Text24: Text25: Text26: Text27: Text28: Check Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffText33: Check Box34: OffCheck Box35: OffText36: Text37: Text38: Text39: Text40: Text41: Text42: Check Box43: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: Off