Campbell County Business Grant Application - COVID 19 Expense Reimbursement

2. 

4. Campbell County businesses who meet eligibility criteria may apply for up to $5,000 in reimbursement funds via the online grant application below. Campbell County’s internal COVID-19 Finance Team will review applications and make award recommendations starting July 1 and will continue as long as allocated resources remain available. Award recipients will be notified by email; awards will be issued by check or direct deposit. Requests for grant awards over $5,000 will be considered on a case-by-case basis contingent on documentation of adverse impact and need.

   Campbell County businesses who meet eligibility criteria may apply for up to $5,000 in reimbursement funds via the online grant application below. Campbell County’s internal COVID-19 Finance Team will review applications and make award recommendations starting July 1 and will continue as long as allocated resources remain available. Award recipients will be notified by email; awards will be issued by check or direct deposit. Requests for grant awards over $5,000 will be considered on a case-by-case basis contingent on documentation of adverse impact and need.

6. Applicants should be aware of the following criteria set for eligibility: 1. Funds must be used for actual COVID-19 expenses related directly to the public health crisis (i.e. cleaning supplies, masks for employees, plexi-glass installation, hand-sanitizer, etc.) Grant funding does not cover loss of revenue or reimbursement for tax payments. 2. Reimbursable expenses must have been incurred between March 1 and December 30, 2020. 3. Copies of dated receipts and a completed W-9 form must be submitted with the application to be considered. 4. Each business location requires an individual application.

   Applicants should be aware of the following criteria set for eligibility: 1. Funds must be used for actual COVID-19 expenses related directly to the public health crisis (i.e. cleaning supplies, masks for employees, plexi-glass installation, hand-sanitizer, etc.) Grant funding does not cover loss of revenue or reimbursement for tax payments. 2. Reimbursable expenses must have been incurred between March 1 and December 30, 2020. 3. Copies of dated receipts and a completed W-9 form must be submitted with the application to be considered. 4. Each business location requires an individual application.

8. To apply for funding, your business must: o be independently owned; (corporately owned national chains are not eligible for the grant unless they are an individually owned franchise). o hold an active business license in Campbell County. o be in good standing on state/local taxes. o be physically located in Campbell County. o have been in operation since 2019.

   To apply for funding, your business must: o be independently owned; (corporately owned national chains are not eligible for the grant unless they are an individually owned franchise). o hold an active business license in Campbell County. o be in good standing on state/local taxes. o be physically located in Campbell County. o have been in operation since 2019.

10. Business owners with questions may contact the Department of Finance and Strategic Initiatives at (434) 332-9667.

    Business owners with questions may contact the Department of Finance and Strategic Initiatives at (434) 332-9667.

12. Business Name*

13. Business Phone*

15. Business Contact's Name*

16. Business Contact's Phone/Cell*

18. Business Email*

19. Business Contact's Email*

21. Doing Business As:

23. Business Mailing Address*

25. City

26. State

27. Zip Code

29. Business Physical Address *

31. City

32. State

33. Zip Code

35. Business Website

37. Type of Business Format*

    Please check the option that applies, or explain business model/format.

    1. Independently-owned national/regional franchise
    2. Local independent business/LLC
    3. Home-based Business
    4. Other
38. If other, please explain:

40. What Type of Industry Are You In? *

    Please check the box that best applies.

    1. Construction
    2. Manufacturing
    3. Trade/Transportation/Utilities
    4. Information/Communications
    5. Finance
    6. Professional Business Services
    7. Education Services
    8. Health Services
    9. Personal Care Services
    10. Hospitality/Accommodations
    11. Restaurant/Winery/Brewery
    12. Agricultural Services
    13. Retail
    14. Other
41. If other, please explain:

43. Describe in detail business impacts and expenses incurred due to COVID-19.*

    Please include specific dates, actions/responses, and type of expenses incurred.

45. How many full-time employees did you have prior to March 26, 2020?*

46. How many part-time employees did you have prior to march 26, 2020?*

48. How many employees serve at this business location?*

50. In what year did your begin in Campbell County?*

52. Were you forced to close or modify operations during the COVID-19 pandemic? *

    1. Yes
    2. No

53. If you were forced to close, what were the dates of the closure and what expenses were incurred during this time?

55. Based on unexpected COVID-19 expenses since March 2020, how much in reimbursement funding are you seeking?*

56. If over, $5000, please attach additional detailed explanations of COVID impacts and needs.

58. Have you received other COVID-19 relief funding this year?*

    1. Yes
    2. No

59. If so, please list any agencies providing support, how much was awarded, and date funds were received.

61. Please attach copies of COVID-19 related expense receipts (in one PDF document).*

62. Please attach a completed and signed W-9 form (in PDF format).*

64. Bank Name

    If selected to receive a grant allocation, which bank holds the account you'd like the funds sent to? (If none, a check would be mailed directly to your business.)

66. Please provide your account number.

67. Please provide your routing number.

69. Acknowledgement and Signature:
    I attest that the information presented in this application is true to the best of my knowledge and understand that any funds administrated through this grant may be audited for specified use. I agree to comply with all grant criteria set forth and accept responsibility for repayment to Campbell County should funds be expended by me or my affiliated business in a manner prohibited within the grant’s criteria. I understand that Campbell County administers grant allocations within its discretion and is under no obligation to remit funding based on submission of this request. Please note that nothing submitted with this application will be returned to the requestor.

    I attest that the information presented in this application is true to the best of my knowledge and understand that any funds administrated through this grant may be audited for specified use. I agree to comply with all grant criteria set forth and accept responsibility for repayment to Campbell County should funds be expended by me or my affiliated business in a manner prohibited within the grant’s criteria. I understand that Campbell County administers grant allocations within its discretion and is under no obligation to remit funding based on submission of this request. Please note that nothing submitted with this application will be returned to the requestor.

71. Electronic Signature Agreement*

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature on an official letter of award at a later date if selected to receive funding.

    1. I agree.
73. Electronic Signature

75. Date and Time*
    Date and Time

    Date and Time

Leave This Blank:


77. 1. Receive an email copy of this form.
78. Email address

    This field is not part of the form submission.

79. Submit

* indicates a required field