Fairfax Small Business Storefront Recovery Fund - Application

Applicant Name * Required
First Last
Applicant Title * Required
Business Name or DBA * Required
Business Address
Street Address Address Line 2 City State ZIP Code
Contact Phone * Required
Who should check be made out to and mailing address if different from business name and address:
Email * Required
Business Website
Federal Employment Identification Number (FEIN), Social Security Number (SSN) or Tax Identification Number (TIN)  * Required
Town of Fairfax Business License # * Required
BUSINESS INFORMATION
What best describes your industry sector? (e.g., retail, salon, restaurant)
Type of space occupied - please describe the type of space your business is located in. (e.g., approx. 1,500 sq, restaurant, ground floor) * Required
How long has your business been continuously operating in the Town of Fairfax? (e.g., opened in 2010, 10 yrs)
2019 Gross Revenue
Do you own or lease the primary space where your business operates? * Required
- Own
- Lease/Rent
Monthly Rent or Mortgage Payment Amount: * Required
Number of Full-time or Full-time Equivalent Employees, not including the business owner
COVID-19 IMPACT
Please provide a brief narrative of the impact of COVID-19 has had on your business. * Required
Limit 500 words
What were your projected Gross Revenues for March, April and May 2020?
What were your actual Gross Revenues in March, April and May 2020?
Explain how you will use the Small Business Disaster Fund amount if awarded.
Limit 500 words
CERTIFICATIONS
Must check every box to be eligible for funding: * Required
- Select All
- I confirm that my business is engaged in activities that are regulated by the Town of Fairfax and I/we have a license/permit associated to that regulation.
- I certify that my revenue has declined by 40% or more as a result of COVID-19 .
- I agree to provide documentation, if requested, to help verify the economic hardship suffered as a result of the COVID-19, including tax returns, financial statements, and other financial data.
- I agree to document and report economic impact achieved as a result of the program, including but not limited to, jobs created, jobs retained, increased sales, and access to capital.
- I hereby certify that the information provided, contained herein and attached hereto is accurate and correct to the best of my knowledge.
 APPLICANT CONFIRMATION
Please type your name to certify that the statements marked above with "*" are true. * Required
Note: Information submitted will remain confidential to the extent allowed under the Public Records Act.