HURRICANE ISAAC INTAKE APPLICATION

Transcription

1 HURRICANE ISAAC INTAKE APPLICATION INSTRUCTIONS Thank you for your interest in the St. John Small Business Grant & Loan Program (SBGLP). The SBGLP can provide grant and low interest 1 loan awards for qualified businesses and nonprofit organizations. Awards will be 20% grant and 80% loan; (for example, an award may consist of a $10,000 grant + $40,000 loan for a total award of $50,000.) The minimal award is $10,000 and the initial maximum award is $100,000* (a higher maximum award up may be allowed if funding is available) Please follow the instructions below carefully. Only complete applications will be accepted. 1) Review the Initial Criteria to see if you may qualify (see page 2) 2) Review the Documentation Checklist, and bring all required materials to your appointment (see page 25) 3) If you feel that you may qualify, fill out this application 4) You will receive assistance at the intake centers filling out the required forms, but to save time, please attempt to complete the document prior to your appointment *River Region Chamber of Commerce, 394 Belle Terre Blvd, LaPlace, LA *West Bank Community Center, 173 East 3 rd Street, Edgard, LA If you have other question, please call SBGLP Hotline at , Option #5, or open@scpdc.org. We look forward to working with you! While some information may be your best estimate, please provide the most accurate information and be able to provide evidence of this information upon request. 1 First two years, 4% for the remainder of the terms September 22, 2015 Page 1

2 INTAKE APPLICATION Initial Criteria: For the benefits of the St. John the Baptist Small Business Grant and Loan Program (SBGLP), a business or non-profit organization must meet the following criteria: 1. Were you legally in business in St. John the Baptist Parish on or before July 1 st of 2012? Yes No 2. Are you currently in business in St. John the Baptist Parish or an active entity that closed due to Hurricane Isaac and willing/able to reopen in the parish within 3 months of funding? Yes No 3. Do you currently have less than 50 Full Time Employees (FTEs) or (35 hours/week or equivalent considering full and part-time employees)? Yes No 4. Are you eligible to receive federal funding? (NOT debarred) Yes No 5. Are you willing to obtain and maintain flood insurance as required If within the 100 year flood plain? Yes No Miscellaneous Criteria: Non-profits may be eligible based on the earned income portion of their operation. Religious organizations may be eligible based on the secular business components of their operations Bars may be eligible to receive awards; package liquor stores are not. Single and multi-family residential rental properties are not eligible. An owner may participate in a maximum of two awards and the total sum of ownership percentages must be 100%. Notes: Not every business that meets the above basic eligibility requirements will receive a grant/loan award, due to loan underwriting requirements and potential for more eligible awardees than available funds. Eligibility issues that arise during the course of this program implementation will be decided by the Parish via the Policy Clarification / Change Form process. If you answered NO to any of the Initial Criteria questions above, you will NOT be eligible to participate. Please do NOT continue to fill out this application. Page 2

3 SECTION I DEMOGRAPHICS & INFORMATION GENERAL INFORMATION 1. Applicant/Owner Name 2. Title (i.e., President/Managing Member) 3. Contact Phone 4. Address 5. Legal Company Name 6. Doing Business As (if applicable) 7. Date Established 8. Web Site (if any) 9. Business Structure: Individual/Sole Proprietor C Corporation S Corporation Partnership Nonprofit Limited Liability Company or Single-member LLC Note: For a single-member LLC, do not automatically check LLC Notice the new choice combined with Individual/Sole Proprietor. 10. Is Your Firm at least 51%: (check all that apply) Minority-owned? Woman-owned? 11. Pre-Hurricane Isaac Physical Address of Business (NOT P.O. Box or Mailbox Facility) Address City, State, Zip Code Parish 12. Current Physical Address of Business (NOT PO Box or Mailbox Facility) Check if same as Pre-Hurricane Isaac Address Address City, State, Zip Code Parish 13. Current Mailing Address of Business Check if same as Pre- Hurricane Isaac Address Address City, State, Zip Code Parish Page 3

4 OWNERS & CORPORATE OFFICERS 14. List all owners and corporate officers regardless of ownership percentage. All owners with 20% interest are required to provide an insolido (for full amount of loan) personal guarantee. Ownership percentages must total 100%. (If more space is needed to list owners/officers, please list on a separate sheet and attach.) NAME (First, Middle, Last) TITLE (i.e. President Vice-President Secretary, etc. MAILING ADDRESS VETERAN (Yes OR No) MALE/ FEMALE DISABLED (Yes OR No) JOB OUTSIDE OF BUSINESS (Yes OR No) % of OWNER SHIP TOTAL 100% 15. Please list any Affiliate /Subsidiary Companies owned by Applicant s owners (20% or more): 16. Federal Tax ID Number (EIN or Social Security) 17. NAICS code Page 4

5 SECTION II AWARD DETERMINATION 18. Have you received any other business grant or loan from Louisiana or the Federal Government? (including the SBA?) Some of this information will also be required in detail on the next page. Please be consistent. Yes No 19. If yes, please describe the source of those funds, and what you used them for: 20. Did the business experience a tangible (physical) loss as a result of Hurricane Isaac? Yes No 21. Describe physical damage to property, i.e. roof, water, equipment, etc. Page 5

6 22. List all insurance payments you have received due to Hurricane Isaac, specifying amount and reason. You may summarize here as much of the detail can be included in # s 23, 24, and 25. Example: $20,000 Business Interruption UNMET NEED 23. Building/Property Building or Property Damaged in Hurricane Isaac that you either have replaced/repaired (receipts) or if you have not yet been able to Replace or Repair (estimates) Please describe: Replacement Costs OR Cost of Repair (Estimates) Replacement Costs OR Cost of Repair (Actual/Receipts) Insurance Reimbursement OR SBA Assistance (if any) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ 24. Equipment/Inventory Items Damaged or Loss in Hurricane Isaac that you either have replaced/ repaired (receipts) or if you have not yet been able to Replace or Repair (estimates) Please describe: Replacement Costs OR Cost of Repair (Estimates) Replacement Costs OR Cost of Repair (Actual/Receipts) Insurance Reimbursement OR SBA Assistance (if any) $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ Page 6

7 25. Please describe lost revenue and/or any other fiscal impacts that you have not yet described (dollars) UNREIMBURSED EXPENSE 26. Working Capital/Operating Expenses The award amount may include the value of unreimbursed expenses such as wages paid to employees and operating expenses incurred during the time that the business was closed or not fully operational. Number of Employees Retained Full time 2 : Part time: (less than 35 hours per week) 2 Employees= Full Time Equivalents = 35 hours per week minimum Page 7

8 Complete for the time period closed due to Hurricane Isaac. Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Insurance Proceeds or SBA Assistance Revenue $ $ $ $ $ $ $ Expenses - Financials Salary $ $ $ $ $ $ $ Wages $ $ $ $ $ $ $ Rent $ $ $ $ $ $ $ Insurance $ $ $ $ $ $ $ Utilities $ $ $ $ $ $ $ Phone/Internet $ $ $ $ $ $ $ Other* $ $ $ $ $ $ $ Inventory $ $ $ $ $ $ $ Business Debt $ $ $ $ $ $ $ FOR OFFICE USE ONLY Total Expenses $ $ $ $ $ $ $ Operating Profit or Loss (if any) $ $ $ $ $ $ $ IF CLOSED LONGER THAN SIX (6) MONTHS, AN ADDITIONAL PAGE 8 CAN BE PROVIDED UPON REQUEST Page 8

9 Complete for the 6 months beyond the date that your business reopened after Hurricane Isaac. Month 1 Month 2 Month 3 Month 4 Month 5 Month 6 Insurance Proceeds or SBA Assistance Revenue $ $ $ $ $ $ $ Expenses - Financials Salary $ $ $ $ $ $ $ Wages $ $ $ $ $ $ $ Rent $ $ $ $ $ $ $ Insurance $ $ $ $ $ $ $ Utilities $ $ $ $ $ $ $ Phone/Internet $ $ $ $ $ $ $ Other* $ $ $ $ $ $ $ Inventory $ $ $ $ $ $ $ Business Debt $ $ $ $ $ $ $ FOR OFFICE USE ONLY Total Expenses $ $ $ $ $ $ $ Operating Profit of Loss (if any) $ $ $ $ $ $ $ *Examples include costs associated with the protection, clean-up and/or relocation of assets Page 9

10 27. Did the business close as a result of Hurricane Isaac? Yes No 28. If yes, what date did the business reopen? (MM/DD/YYYY) 29. If not reopened, what would it take to do so? 30. When you reopened, describe the time and additional effort that you had to take until business returned to normal? 31. Pre-Hurricane Isaac employees: Number of Employees Pre-Hurricane Isaac Full time 3 : Part time: (less than 35 hours per week) 32. Describe your capability to retain skilled workers after the impact. 3 Employees= Full Time Equivalents = 35 hours per week minimum Page 10

11 33. Is your business currently in trouble? If your business does not receive assistance from the St John Business Grant/Loan Program are you on the verge of closure or layoffs in the near future? Yes No ***If Yes, fill out the Business LMI Form Modified for Job Retention Purpose on pages 18 and 19 (complete with intake officer). 34. Did Hurricane Isaac cause a layoff of employees? If so, please complete the following to include those positions laid-off: Job(s) / Position(s) # of Jobs August 29, 2012 # of current Jobs Total hours per week loss per Job(s)/Position(s) Hourly Rate or Annual Salary FUTURE RESILIENCE AND SUSTAINABILITY 35. As of Today: Number of Employees Current Where it can be shown that businesses reduced their staffing levels due to the aftermath of Hurricane Isaac, subject to the requirements to hire, the value of re-hiring that position(s) may be included in the value of the award as long as the applicant does in-fact add back that position. Estimated Number of New Employees within the next year as a result of this award Full time 4 : Part time: (less than 35 hours per week) Full time 5 : Part time: (less than 35 hours per week) ***If you would be interested in re-hiring lost positions, fill out the Business LMI Form on page 18 & 19 (complete with intake officer). 4 Employees= Full Time Equivalents = 35 hours per week minimum 5 Employees= Full Time Equivalents = 35 hours per week minimum Page 11

12 36. Where an applicant can demonstrate and describe that a new piece of equipment, or a new project that would help the business to become more resilient or sustainable, the award may be increased up to the program caps not to exceed the described additional items. This additional component shall be satisfactorily described in the applicant s business plan in a manner acceptable to the economic development financing standards of the Sub-Recipient s RLF Administrative Board. Please describe your idea to become more resilient or sustainable. 37. The St. John Small Business Grant and Loan Program will require for every $60,000 you receive to create a new job. Are you willing to create a new job for every $60,000 you receive? Yes No ***If No, you can still receive assistance but not over $59,999. ***If Yes, fill out the Business LMI Form Modified for Job Creation Purpose on page 20 (complete with intake officer). 38. Are you willing/able to create a full-time job (W-2 and non-owner) for every $60,000 in funding? Yes No 39. Did you have a minimum $35,000 annual gross revenue for one of the 3 years (2010, 2011 or 2012)? Yes No If No for 39, 2012 can be prorated to consider the effects of Hurricane Isaac and additional monthly financial data will be requested to determine your eligibility. Page 12

13 EXISTING BUSINESS DEBT SECTION III FINANCIAL/UNDERWRITING 40. Please list any/all business debt PLEASE LIST ALL EXISTING BUSINESS and PERSONAL DEBTS DEBT SCHEDULE * Date: Creditor Original Amount Original Date Present Balance % Rate Maturity Date Monthly Payment Security (collateral) ** Total Present Balance: Total Monthly Payments: * Should be the same date as current financial statement. ** Total must agree with balance shown on current financial statement. Page 13

14 GRANT AND LOAN REQUEST (USE OF FUNDS) The St John Small Business Grant/Loan Program will fund awards for working capital, inventory and moveable & limited immoveable equipment to help you recover from Hurricane Isaac. Awards will be in the form of a Grant and Loan package whereby 80% of the total will be a low interest loan to be repaid within a 5-7 year term and 20% of the total award will be a Grant that will not have to be repaid, but will be taxable as income 41. In the initial consideration, awards will range from $10,000 to $100,000. What amount are you requesting and what would the funds be used for? Working Capital/Operating Expenses Wages to keep existing employees? $ Wages to hire new employees? $ Rent $ Per month for 6 months $ Insurance $ Per month for 6 months $ Utilities $ Per month for 6 months $ Other (Please describe): $ Inventory (Please describe below): $ Page 14

15 Moveable & Limited Immoveable Equipment Items Damaged or Lost in Hurricane Isaac that you now want to Replace or Repair (Please describe) Replacement Costs OR Cost of Repair (Estimates) Insurance Reimbursement OR SBA Assistance (if any) $ $ $ $ $ $ $ $ $ $ Moveable & Limited Immoveable Equipment New Items that could help your business become more resilient or sustainable (Please describe) $ $ $ $ $ Costs Project New Project that could help your business become more resilient or sustainable (Please describe) $ $ $ $ Costs $ 42. If the $100,000 Cap could be increased, would you increase your request? Yes No Page 15

16 43. List your earnings, projections for the following three years (after receiving the award): YEAR 1 Gross Income $ Cost of Goods Sold $ Expenses $ Adjusted Gross Income $ YEAR 2 Gross Income $ Cost of Goods Sold $ Expenses $ Adjusted Gross Income $ YEAR 3 Gross Income $ Cost of Goods Sold $ Expenses $ Adjusted Gross Income $ Page 16

17 44. Is there any other information you would like to provide about your need for assistance? 45. How did you hear about this program? THE REMAINDER OF THIS APPLICATION MUST BE COMPLETED BY HAND and/or IN PERSON WITH YOUR INTAKE OFFICER. Page 17

18 Business LMI Form Modified for Job Retention Purposes Effective Date: March 16, 2015 Business: St John Small Business Grant and Loan Program - Initial Recovery Disbursement Physical Address: (of Business) Federal Tax ID: (Business) Reporting Period: Begin End Parish: (Income Area) Instructions: St. John the Baptist One Person Income: 33,600 Employment Positions: Job/Position Title Parish of Business' (Physical Address) - Combine multiple jobs on one row ONLY if Position Title and Wages/Compensation are the same. Check ONE: Total Employment # of Jobs August 29, 2012 # of current Jobs Jobs in Jeopardy Hours per Week Hourly Rate or (HUD Limit 2015) Annual Salary or 0 0 This information is required by HUD and used for aggregate reporting Signed: Date: Wages/Compensation (enter as Hourly Rate OR Annual Salary) FTE's LMI Non- LMI Page 18

19 Page 2 Business LMI Form Modified for Job Retention Purposes Effective Date: March 16, 2015 Business: St John Small Business Grant and Loan Program - Initial Recovery Disbursement Employment Positio Job/Position Title Check ONE: # of Jobs August 29, 2012 # of current Jobs Jobs in Jeopardy Hours per Week Wages/Compensation (enter as Hourly Rate OR Annual Salary) Hourly Rate or Annual Salary FTE's LMI Non- LMI or Total Employment 0 0 Page 19

20 Grantee/Sub- St. John Small Business Grant and Loan Program Business LMI Form Modified for Job Creation Purposes Effective Date: March 16, 2015 (Client Served or Physical Address: (of Business) Federal Tax ID: (of Business) Reporting Period: Begin End Parish (Income Area): St. John the Baptist One Person Income: 33,600 Instructions: (Parish of Business' Physical Address) (HUD Limit 2015) - Combine multiple jobs on one row ONLY if Position Title and Wages/Compensation are the same. Employment Positions: Job/Position Title Check ONE: Total Employment # of New Jobs Created Hours per Week Wages/Compensation (enter as Hourly Rate OR Annual Salary) Hourly Rate or or Annual Salary LMI FTE's Non- LMI 0 0 This information is required by HUD and used for aggregate reporting Signed: Date: Page 20

21 46. STATEMENT OF UNDERSTANDING (Please read and initial each paragraph if you agree) SBA Duplication of Benefits. The Small Business Administration will review all award recipients for "Duplication of Benefit." If it is found that you received an SBA loan for your business for the purpose of repairing or replacing physical damage (i.e., equipment or inventory) due to Hurricane Isaac, the value of the SBA assistance may be deducted from your award. Louisiana Department of Revenue. The undersigned understands that the Small Business Grant and Loan Program (''SBGLP) have the authority to confirm with the Louisiana Department of Revenue that the award recipient is in good standing with Louisiana Department of Revenue. Award recipient must be in good standing in order to receive award funds. If the Louisiana Department of Revenue cannot verify that the award recipient is in good standing they will notify LED, and a letter will be issued to the award recipient informing them that they should contact the Department of Revenue to discuss their account. Income Tax Reporting. The undersigned understands that an IRS 1099G will be issued to award recipients. Award recipient understands that all or a portion of the Grant funds may be treated as taxable income for U.S. or state income tax purposes. Public Announcements. If the award recipient wishes to issue a public announcement concerning this award, the text of the proposed announcement must be submitted to the SBGLP for review and approval prior to the release date. The Louisiana Department of Economic Development (''LED"), the Office of Community Development ("OCD") and St. John the Baptist Parish must be mentioned in any public announcements. Approval shall not be unreasonably withheld. No Right of Assignment or Delegation. The award recipient may not assign or otherwise transfer its rights or delegate any of its obligations under this letter unless expressly approved by LED and OCD. Revocation. SBGLP reserves the right to revoke this award if the funds are not used-for the stated purpose. The award recipient understands and agrees that revocation of this award will require the return of all funds disbursed. The business will be obligated to repay some or all funds received under this program in the event that (a) its application including any information provided therewith or thereafter contains any material misrepresentations; or (b) the award was made in error and the applicant is not entitled to some or all assistance under the Program Guidelines. Page 21

22 Monitoring and Records a. This award may be used only for the purposes stated herein. Documents providing evidence of the use of the funds from this award shall be retained by award recipient for five years from the date of disbursement of the initial installment of the award. b. SBGLP reserve the right to monitor usage of award funds. Such monitoring will include review that the entire amount of the award was used only for the expenses as specified above in accordance with your proposal. c. LED/OCD, St John the Baptist Parish and/or SCPDC may, during regular business hours and on reasonable notice to award recipient inspect, audit, or copy records pertaining to this award. It is further agreed that the Louisiana Department of Economic Development, Legislative Auditor of the State of Louisiana, the Office of Community Development, Division of Administration, and/or the U.S. Department of Housing and Urban Development auditors or auditors contracted by them shall have the option of auditing all records and accounts of award recipient that relate to this Grant at any time during normal business hours, as often as deemed reasonably necessary, to audit, examine, and make excerpts or transcripts of all relevant data. d. Awardee s failure to cooperate in such review will result in forfeiture of the award Amount and awardee will be responsible for repaying the full amount of funds disbursed. Information Access Authorization: For determination of eligibility, the applicant should submit information requested in the Application Checklist. In the event that additional information not included with the initial application checklist is required to obtain an approval for the application, the undersigned agrees to provide that information in a timely manner to the loan officer processing the request. The undersigned gives permission to SBGLP to confidentially discuss any application information with all intermediaries involved with this Program. The applicant also gives permission to SBGLP and its intermediaries to use its name in its Annual Report and in its marketing materials. No financial details will be released, except possibly for award amount, as this is considered public information. The undersigned authorizes SBGLP and its intermediaries to obtain personal credit reports and business credit reports, and also acknowledges that all information relative to the loan request, including the application and related documentation, becomes the property of SBGLP and will not be returned to the applicant. Affirmation of Information Provided in Application. By the applicant's signature below, the applicant represents and warrants that he/she has read this application and Statement of Understanding and attests that all information and documentation furnished in connection with the application is true, accurate and complete to the best of his/her knowledge and that any regulations relative to the SBGLP program will be followed. Individuals and/or businesses found to be willfully providing fraudulent information may be prosecuted. Page 22

23 47. SIGNATURES All owners with at least 20% ownership must sign the application, or the applicant must provide a Board Resolution Authorizing the application. A Board Resolution will also be required prior to closing APPLICANT BUSINESS NAME: 1. OWNER NAME: SIGNED: TITLE: DATE: 2. OWNER NAME: SIGNED: TITLE: DATE: 3. OWNER NAME: SIGNED: TITLE: DATE: 4. OWNER NAME: SIGNED: TITLE: DATE: 5. OWNER NAME: SIGNED: TITLE: DATE: Rev. 09/21/15 Page 23

24 CREDIT AUTHORIZATION FORM I HAVE APPLIED FOR A St John Small Business Grant & Loan Program Award/Loan. This form will authorize South Central Planning and Development Commission to: 1. Order a credit report on said individual including all 20% owners from any credit agency of SCPDC s choice (a separate form to be filled out on each owner). 2. Obtain any information from any source necessary in underwriting this application 3. Obtain any sales/use tax information necessary. I am aware that the process for the loan approval means that this information becomes part of what can be considered public information. Print Full Name of Individual: First Middle Last Current Mailing Address: City State Zip Current Physical Address: City State Zip Previous Address: City State Zip Social Security Number: Date of Birth: I attest that all information contained here with in understood by me, the undersigned. Signature Date Page 24

25 ELIGIBILITY DOCUMENTATION CHECKLIST Need ( ) Document Date Completed Loan Application Personal Tax Returns 2012, 2013, 2014 Business Tax Returns 2012, 2013, 2014 Evidence of $50K annual gross revenue in either 2010, 2011, 2012 Financial Statement Current Personal Financial Statement Current Year-To-Date Business 3 Fiscal Year-end financial statements (2012,2013,2014) Monthly financial statements July 2012 thru December 2012 Articles of Incorporation and By-Laws Credit Authorization Form for each individual 3 year projections going forward W-9 Form Current Occupational License Balance Sheet and Income Statement Names of affiliated/subsidiary businesses Copy of Current Government-Issued ID for all owners/principals Proof of Business/Ownership Structure Proof of Number of Employees (copy of 941) Proof of Address (copy of utility bill) Business LMI Form Page 25

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