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2. Business Name*
3. Business Street Address*
5. Business Zip Code*
6. Business Tax ID*
8. Business UEID Number*
9. Business Type*
11. Business Owner Name*
12. Business Owner Email*
14. Business Owner Phone Number*
15. Business Owner Residential Address*
17. Section 1

    Eligibility Criteria

    Answers to the following questions are required in order to determine grant eligibility.

    Provide documentation for the response to each answer. 

19. How many full time and full-time equivalent employees does your business employ? *
20. Has your business experienced hardship recruiting and retaining employees due to the COVID-19 pandemic (since March 2020)?*

    1. Yes
    2. No
22. Please specify: *
24. Do you need assistance with employee recruitment and retention? *

    1. Yes
    2. No
25. Do at least 90% of employees (full-time and part-time) at your business receive a pay rate of less than or equal to $50,150 annually?  *

    1. Yes
    2. No
27. Section 2: Business Information
29. Select the business type that best describes your business:*

    1. Agriculture & Forestry
    2. Marketing, Technology and other Business Services
    3. Construction, Utilities, Contracting Services
    4. Childcare and Education Services 
    5. Motor Vehicle 
    6. Personal Services (personal care, entertainment, fitness, photography, cleaning, etc.) 

    1. Real Estate & Housing
    2. Finance/Accounting, Insurance, and Taxes
    3. Transportation
    4. Food and Hospitality
    5. Healthcare services 
    6. Other
31. Please Specify*
33. *Important Note about Eligibility: gun shops, pawn shops, cannabis businesses, franchises of national or regional chains, social clubs, home-based business and adult entertainment businesses are not eligible for this grant.
35. What year was your business established in Livonia?*
36. Are your property taxes and water bills current? *

    1. Yes
    2. No
38. Does the business have any outstanding code enforcement violations?*

    1. Yes
    2. No
39. Have applied for and/or received any other business aid support through any other local, state and/or federal government, foundation, or any other business aid program since March 16, 2020? *

    1. Yes
    2. No
41. Businesses that are a part of the program will be expected to self-certify that they are not receiving a small business grant from another government entity, non-profit, faith-based group or other non-governmental entity. This form will be required to be filled out at the time of signing the grant agreement. If self-certification is discovered to be false, the grantee is responsible for 100% repayment of funds to the City of Livonia.
43. Source*
44. Amount*
46. Purpose*
47. Approved for such funds?*

    1. Yes
    2. No
49. Second Source
50. Amount
52. Purpose
53. Appoved for such funds?

    1. Yes
    2. No
55. Third Source
56. Amount
58. Purpose
59. Approved for Such Funds

    1. Yes
    2. No
61. Section 3: Employment Information Information entered in this section should represent the circumstances of the business for which you intend to use any grant funds. When calculating total employees, include yourself and all full-time and part-time employees.
63. How many total full-time workers did you employ in 2019? *
64. How many total part-time workers did you employ in 2019? *
66. How many total full-time workers did you employ in 2020? *
67. How many total part-time workers did you employ in 2020? *
69. How many total full-time workers do you employ today?*
70. How many total part-time workers do you employ today? *
72. How many unfilled full-time jobs do you have today? *
73. How many unfilled part-time jobs do you have today?*
75. Please explain any changes you have made to your workforce because of the COVID-19 crisis:*
77. Section 4: Financial Information Answer the following questions to the best of your ability. Applications will be evaluated based on the information provided.
79. What was your annual (gross) revenue in 2019? *
80. What was your annual (gross) revenue in 2020? *
82. What was your annual (gross) revenue in 2021? *
84. What is your estimated revenue loss since March 1, 2020? How much revenue has the COVID 19 crisis cost you?*
86. How much revenue do you anticipate you will lose due to staffing shortages in the next six months?*
88. How has your business had to change its recruitment practices since the start of COVID 19 (March 1, 2020)?*
90. Have you increased your starting pay rate?

    1. Yes
    2. No
91. Have you offered signing bonuses? *

    1. Yes
    2. No
93. What other recruitment practices have you enacted since March 1, 2020?*
95. Monthly Working Capital Costs (amount expended during a typical month for the following expenses):
97. Cost of goods sold: 
98. Prior to COVID (2019) *
99. Today*
101. Rent/mortgage: 
102. Prior to COVID (2019) *
103. Today*
105. Gas and electric: 
106. Prior to COVID (2019) *
107. Today*
109. Water and drainage: 
110. Prior to COVID (2019) *
111. Today*
113. Insurance - general liability, property, workers comp, & others - total: 
114. Prior to COVID (2019) *
115. Today*
117. Taxes - income, sales, payroll, property & any other outstanding tax liability: 
118. Prior to COVID (2019) *
119. Today*
121. Subscription services - internet, POS, & other: 
122. Prior to COVID (2019) *
123. Today*
125. Payroll: 
126. Prior to COVID (2019) *
127. Today*
129. Debt service: 
130. Prior to COVID (2019) *
131. Today*
133. Additional monthly expenses (include explanation and dollar amounts): 
134. Prior to COVID (2019) *
135. Today*
137. Section 5: Other Information – Your Business Story
139. How has your business been affected by COVID?*
141. Are you aware of the City of Livonia's programs and are you interested in learning more about we can do? *

     1. Yes
     2. No
142. Does your company have 5 or fewer employees? *

     1. Yes
     2. No
144. Please submit the following:

     Completed W9 form 

     Business bank statements (last 2 months) 

     Business incorporation documents 

146. Section 7: LIST OF DOCUMENTS THAT MAY BE REQUIRED TO CONDUCT UNDERWRITING

     DBA License/Certificate from the State of Michigan 

     Most recent business tax return filed. 

     Proof of quarterly tax payments if made quarterly 

     Profit and Loss Statement for the prior two years and quarterly for the current year. 

     Bank statements for the prior two months. 

     Balance sheet prior three years 

     Current balance sheet no older than 90 days 

     Copy of lease or rental agreement, or mortgage, for your commercial premises in Livonia if you are seeking SBG assistance for commercial lease/rent/mortgage. 

     Copy of lease, rent, or mortgage statement showing you are CURRENT on lease, rental agreement, or mortgage 

     Copy of utility bills for utilities for which you seek SBG assistance. 

     Statement of cash flows 

     Signed AFFIDAVIT regarding receipt of other funds. 

     IF YOU ARE A LOW/MOD INCOME OWNER OF A MICRO ENTERPRISE, your most recent personal tax returns are required. 

     Payroll reports for prior year and quarterly reports for current year. 

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148. 1. Receive an email copy of this form.
149. Email address

     This field is not part of the form submission.

150. Submit

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