City of McHenry Restaurant and Tavern Relief Fund Application

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Date of Submittal*field type date
Requested Grant Amount*field type currency
$
Business Legal Name*field type single line
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Doing Business as (DBA) or Trade Name*field type single line
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City, State, Zip*field type single line
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Industry Type (NAICS Code)field type single line
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Contact Information

Person/people responsible for this application and the actual implementation of the project; list all applicable
Contact Information
Person/people responsible for this application and the actual implementation of the project; list all applicable
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- Title(s)*field type single line
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- Address*field type single line
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- Phone*field type single line
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- Cell Phone*field type single line
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- Email*field type email
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Date of Establishment*field type date

Establishment Information

Type of Entity*field type radio button
Type of EntityLimited Liability CompanyCorporationSole ProprietorshipPartnership

Management

Name(s)*field type single line
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Title(s)*field type single line
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Percentage Ownership*field type single line
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Describe the company/organization and how your organization/company has been negatively impacted by COVID-19 including amount/type of loss (revenue, cost of business interruption, employees, equipment, product, etc.) Is business closed, how long? Please be specific.*field type multi line

Describe Employment and Wages

Current # of Employees*field type single line
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Direct Annual Payroll*field type single line
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Number of employees salaries reduced*field type single line
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Percentage of Employees that had earnings that were impacted*field type single line
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Percent Living in City of McHenry*field type single line
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Percent Living in McHenry County*field type single line
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Jobs/Employees Lost/Laid Off*field type single line
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Total Number of Employees prior to COVID-19*field type single line
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Building Ownership Information

Building Owner Name, Address, Email, Phone*field type single line
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Square footage of Unit/Building*field type single line
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Lease Renewal Date (if applicable)*field type single line
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Describe Activities and operations performed at your locationfield type multi line
Is your business facing imminent closure?*field type single line
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Emergency Contact Informationfield type single line
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How would you like to receive payment if approved?*field type radio button
How would you like to receive payment if approved?Direct DepositU.S. Mail
Routing Numberfield type single line
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Account Numberfield type single line
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Address for paymentfield type single line
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Required Attachments:

A. Business Plan (history of business and market information identifying company products and services as well).
B. W-9 Form
C. Monthly ST-1 Sales and Use Tax Forms that were submitted to the State of Illinois for each month from March to September 2019 and March to September in 2020. Sales should be isolated at a McHenry location only.
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Business Certifications

I, the undersigned, hereby certify that the applicant/business is a business in good standing, authorized to do business in Illinois and has no delinquent tax liabilities. No tax liens have been filed, including but not limited to state, county, municipal or federal against the business, any partners of the business, the majority of shareholders of the business, or in the name of any related business owned by the recipient.
I further certify that all information contained within this application or submitted by me to the City of McHenry on behalf of the business, is subject to the Freedom of Information Act, with the exception of all business and personal financial information which I am hereby requesting to be maintained strictly confidential by the City of McHenry.
I further certify that the applicant/business is an equal opportunity employer and does not discriminate on the basis of race, creed, color, sex, religion, age, national origin or ancestry, physical or mental handicap, marital status or matriculation. I further certify that I understand any monetary reimbursement provided to the applicant/business may be subject to and/or contingent on the applicant/business paying prevailing wage, consistent with the Illinois Prevailing Wage Law.
I certify that all information in this application, including all documentation and attachments, is accurate, complete and true to the best of my knowledge and belief.
Signatures
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- Acknowledgement*field type checkbox
  AcknowledgementI understand that checking this box constitutes a legal signature and confirms that I have filled out this form to the best of my ability.
- Signature*field type signature
- Title*field type single line
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- Date*field type date
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City of McHenry Restaurant and Tavern Relief Fund Application

Contact Information

Contact Information

Establishment Information

Management

Describe Employment and Wages

Building Ownership Information

Business Certifications

Signatures