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L,6 <br />B"IsfVille Emergency Solutions Grant Program Application <br />COLORADO • 81NCE 1878 <br />for Louisville Small Businesses Impacted by the COVID-19 Pandemic <br />❑ Business has experienced or is projecting to experience a significant decline in revenue as a <br />result of the COVID-19 pandemic <br />❑ Business is in good standing with the City of Louisville with respect to taxes and fees; and is <br />in good standing with the County, State, and Federal governments <br />❑ Business is in Good Standing with the Colorado Secretary of State (the City will verify you <br />have a Good Standing Certificate) <br />❑ Business is engaged in activities that are legal under City and State law <br />❑ As of March 10, 2020, business is not subject to an administrative order, civil lien, or civil <br />judgment held by or on behalf of any federal, state, county, or municipal government; political <br />subdivision; or special district; or criminal restitution order <br />❑ Any grant monies received will be used on business -related expenses in Louisville, including <br />rent, mortgage, payroll, or other essential payments needed in order to stay in or restart <br />operations. Eligible expenses also include those related to purchases or changes needed to <br />operate during the pandemic <br />Business Signature: <br />Business Signature Title: <br />Date: <br />Other Information (this section is not required; the data is helpful to understand future <br />strategies for business support but will not be used to evaluate your application) <br />Number of current employees or number anticipated through April 30, 2020: <br />• Full-time: <br />• Part-time: <br />• Total: <br />Based on the Governor's Executive Orders, was your business (select one): <br />• Defined as non -critical and forced to close for the Order duration <br />• Defined as non -critical and shifted to online only orders or offerings <br />• Defined as critical but must restrict operations (offer only take-out/delivery, etc.) <br />• Defined as critical and allowed to operate while implementing remote work or changes <br />to work places for social distancing/sanitizing <br />