2021 RICE COUNTY COVID-19 Business Relief Payments Application

2. Name Of Business/DBA*

4. Address*

6. Business Phone Number*

8. Email Address*

10. Name of Person responsible for this application and information provided*

12. Federal Tax ID#*

14. State of MN Business Tax ID #*

16. Number of current Full Time or Full Time equivalent employees*

18. Number of current Part Time employees*

20. Number of employees FT or PT that have been laid off due to COVID-19 Executive Orders: *

22. Month/Year business or ownership established*

24. Is your business located in Rice County?*

    1. Yes
    2. No

26. Is your business still active? *

    1. Yes
    2. No

28. Has your business been directly impacted by being ordered to be closed or at reduced capacity by an Executive Order related to COVID-19? *

    1. Yes
    2. No

30. Has your business been indirectly impacted by an Executive Order related to COVID-19? *

    1. Yes
    2. No

32. What is your NAICS industry code (if known)? *

34. Description of financial need. Explain in detail how your business has been affected by COVID-19. (free form)*

36. Do you have any liens with the MN Secretary of State? *

    1. Yes
    2. No

38. Were business property taxes paid in full as of March 1, 2020? *

    1. Yes
    2. No

40. Have you been notified by the Department of Revenue that you will be receiving business relief funds? *

    1. Yes
    2. No

42. Please list the dates & amounts received of any other COVID-related relief funds including, but not limited to, Paycheck Protection Program, DEED programs, or Rice County Business or other City CARES funds, etc. Note: Receipt of prior funding does not automatically exclude you from this application.*

44. Please describe how COVID-19 Executive Orders have negatively impacted your business and provide a statement of financial loss. Businesses in existence prior to 2020 may demonstrate impact by submitting November/December 2019 and November/December 2020 profit and loss or sales statements. New businesses may demonstrate impact by submitting anticipated business plan revenue or sales statement and actual revenue or sales data. Please be thorough in your response as this information will play an important role in the distribution of funds.*

46. Please provide information on how the requested grant funds will be used in accordance with the grant program guidelines and how it will impact the future of your business?*

48. Signature*

    I hereby agree that by signing the Rice County COVID-19 Business Relief Payments application I claim all information is accurate and that I am subject to audit by RIce County for the information given. If it is determined that the information provided is not accurate, I agree to pay Rice County the entire grant that I receive. I acknowledge that some data provided may be public and will be governed by the Minnesota Data Practice Law.

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50. 1. Receive an email copy of this form.
51. Email address

    This field is not part of the form submission.

52. Submit

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