Chambord Place Fire Relief Grant Application 2022

Business Contact Information

Please complete the following section so the Hoboken Relief Fund Grant Committee may contact you with any questions, clarifications or requests for additional information. Thank you!

Date / Time of Grant Application Submission

Date

Time

Business Name: *

Name of Principal Contact *

First

Last

Title of Principal Contact: *

Business Address: *

Address Line 1

Address Line 2

City

State

Business Phone Number: *

Business Email Address: *

URL of Business Website:

Please provide a description of your business: *

What Year was your Business Established? *

Federal Employer Identification Number (EIN) *

Financial Information

Please complete this section with all pertinent financial information current to the date of grant application submission.

Is this your primary source of income? *

Note: If "no", the Grant Committee will contact you for further clarification of need.

What is your monthly lease amount? *

Please upload a copy of lease agreement: *

Click or drag files to this area to upload. You can upload up to 5 files.

The following document types are accepted: .doc, .pdf, .png, .jpg

Monthly Payroll Expenses: *

If none, please enter "0".

2021 Annual Revenue: *

Please upload your draft 2021 tax filing. **If you have not yet filed or drafted your 2021 taxes then you MUST upload your 2020 tax return AND 2021 financial statements** *

Click or drag files to this area to upload. You can upload up to 5 files.

The following document types are accepted: .doc, .pdf, .png, .jpg

Notes or comments regarding Business Revenue and Expenses (if any):

What was the 30-day business revenue from December 22, 2021 - January 22, 2022? *

Have you been able to relocate your business since the fire? *

Please select the option from the dropdown menu that best describes your relocation situation.

Insurance Information

Please complete this section with the most current insurance information as per the date of the grant application submission.

Estimated total asset loss to your business, due to the fire, including inventory, equipment and other physical assets :

Please upload and provide all claims filed with your insurance company as relates to losses from the fire (if any).

Click or drag files to this area to upload. You can upload up to 5 files.

The following document types are accepted: .doc, .pdf, .png, .jpg

Please upload details of business/property insurance policies, if any.

Click or drag files to this area to upload. You can upload up to 5 files.

The following document types are accepted: .doc, .pdf, .png, and .jpg. Examples of Insurance Coverage Could Include: -Improvements and betterments coverage -Business personal property and stock -Business interruption coverage

Have you received payments from your insurance company? If yes, please upload documentation.

Click or drag files to this area to upload. You can upload up to 5 files.

The following document types are accepted: .doc, .pdf, .png, .jpg

If you have raised funds after the fire via GoFundMe, or a similar campaign, please provide the dollar amount raised.

How will access to this Hoboken Relief Fund grant assist your business to survive? *

Please let us know how you will use this grant to reactive and rebuild your business in Hoboken.

Verification and Agreement

Upload a Photo ID of Authorized Business Representative Noted Above: *

Click or drag files to this area to upload. You can upload up to 3 files.

The following document types are accepted: .doc, .pdf, .png, .jpg

Do you accept the following terms and conditions? *

If awarded grant funds, I and the related owners and employers of our business will: A. Spend the grants funds in a safe and sound manner to help position the business for survival and recovery; B. Retain existing and rehire laid off staff and pay them fair wages; C. Avoid any fraud, waste or abuse of funds; and D. Guarantee repayment of grant funds if found to have willfully not complied with grant program rules. The information contained herein and as attached is true and complete to my knowledge and belief. As a principal for the aforementioned business/company, I have full authorization to apply on its behalf. It is fully understood that the information will be utilized to determine the eligibility to receive monetary relief in response to the fire. I agree to respond to follow-up questions and/or requests for additional information in a timely and accurate manner in support of review and processing of my application for grant funds. I certify that the request for assistance is directly related to the fire and not an attempt to defraud the City/County/Federal Government. I further authorize and acknowledge that if deemed eligible for assistance, the business/company and this application is subject to audit and the business/company will be held liable for any misuse of funds inclusive of possible incarceration. In consideration of this application and all of the documentation provided, will not be discriminated against based on age, race, creed, color, religion, sex, sexual orientation, national origin, disability, marital status or any other basis that is prohibited by the United States federal, state, or local law. I, as authorized representative of the Applicant, agree that all of the information submitted is accurate and if awarded grant funds will follow all terms and conditions specified in the Grant Agreement and subsequent revised notices as needed.

Please type your name to act as your Electronic Signature to verify all submitted information is accurate to the best of your abilities and knowledge.