Page Title | OC Workforce & Economic Development Division

Orange County Microbusiness Grant Application

Section 1: Business & Owner Information

First Name

Last Name

Confirm Email

Mobile Phone

Confirm Mobile Phone

Business Name

DBA (Doing Business As)(Note: If No DBA type None)

Business Address

Business Address 2

City

State

Zip

Business Phone

Business EIN or SSN for 1099 Employees

CA Tax ID (If applicable)

Is your business current on all state of California tax obligations?

Yes

DUNS (If you have one)

Business Type

NAICS Code

Business Legal Structure

State of Incorporation

Date Business Established

Business Website URL

Number of Business Locations

Business Industry

Number of Full Time Employees

Number of Part Time Employees

Lowest Wage Paid ($ per hour)

Highest Wage Paid($ per hour)

Annual Gross Revenue (Most recent tax year)

Annual Net Revenue (Most recent tax year)

Owner First Name

Owner Last Name

Owner Address 1

Owner Address 2

Owner City

Owner State

Owner Zip

Owner Email

Owner Mobile Phone

Owner DOB

Owner Race

Owner Ethnicity

Percentage of Ownership of business (Please enter a number between 0 and 100)

Who is your customer base?

What does your business do?

What type of business is it?

Tell us more

Women-Owned Business?

Yes

Veteran-Owned Business?

Yes

Disabled-Owned Business?

Yes

Minority-Owned Business?

Yes

Is the Business a Franchise?

Yes

Is the business located in a low-wealth community?

Yes

Is the business located in a rural area?

Yes

Section 2

Did the microbusiness owner receive a grant under the California Small Business COVID-19 Relief Grant Program funded by Governors Office of Business and Economic Development ?

Yes

Was the business open prior to December 31, 2019?

Yes

The business is currently active and operating?

Yes

The microbusiness was significantly impacted by the COVID-19 pandemic?

Yes

If yes, please describe in how and why:

Did the microbusiness have less than fifty thousand dollars ($50,000) in gross revenues in the 2019 taxable year? (Income from all sources prior to deductions/expenses)

Yes

Does the business have fewer than five full-time equivalent employees and had fewer than five full-time equivalent employees in the 2019 and 2020 taxable years?

Yes

Is the business excluded from participation in the California Small Business COVID-19 Relief Grant Program, as specified in paragraph (2) of subdivision (f) of Section 12100.82 ?

Yes

Section 3

Is the microbusiness owner the majority-owner and manager of the qualified microbusiness?

Yes

The microbusiness is the owner’s primary means of income in the 2019 taxable year was the qualified microbusiness?

Yes

The microbusiness owner did not receive a grant under the California Small Business COVID-19 Relief Grant Program?

Yes

The microbusiness owner can demonstrate their eligibility as a “qualified microbusiness owner” by providing the fiscal agent with a government issued photo identification (state, domestic, or foreign), and documentation that includes the owner’s name and may include, but is not limited to, the following:( (A) A local business permit or license. (B) A bank statement. (C) A tax return.)

Yes

Section 4: User Agreements

(1) I certify under penalty of perjury that I will make eligible purchase with grant proceeds no less than accumulative of $2,500 on or before April 30, 2023.

Yes

(2) I certify under penalty of perjury that I will provide Orange County with official receipts using the county established grant portal for eligible purchases made with grant processed between the period of June 1, 2022 through April 30, 2023.

Yes

(3) I certify under penalty of perjury the undersigned signatory is a duly authorized representative and owner of the Applicant and has full authority to make the certifications referenced herein on the Applicant’s behalf.

Yes

(4) I certify under penalty of perjury the Applicant is currently an active business operating since at least December 31, 2019. The Applicant is currently operating or has a clear plan to re-open once the State of California permits re-opening of the business. The Applicant acknowledges and agrees that if the Applicant receives a grant and the Applicant’s business ceases to operate, the Applicant may be subject to return of all or any portion of such grant.

Yes

(5) I certify under penalty of perjury the Applicant has a principal office in the State of California and, subject to the certification made in (4), above, is presently operating in the State of California.

Yes

(6) I certify under penalty of perjury the Applicant’s business has been adversely impacted by COVID-19 and the health and safety restrictions have resulted in business interruptions, business closures, or similar impacts incurred as a result of the COVID-19 pandemic, making the grant request made in the Applicant’s application necessary to support the ongoing operations of the Applicant.

Yes

(7) I certify under penalty of perjury the Applicant acknowledges and agrees that the Applicant is not one or more of the following types of businesses deemed ineligible to receive a grant under the Program: (a) a government entity (other than an entity owned and/or operated by a Native American tribe) or elected official office; (b) a business primarily engaged in political or lobbying activities; (c) a passive business, investment company or investor who files a Schedule E on its tax returns; (d) a church or other religious institution, other than a school, child care, or other educational business affiliated with a church or other religious institution where (i) greater than 50% of the gross annual revenue (as reflected on the entity’s most recent tax return (2019)) is derived from the school, child care facility or other educational business and (ii) the Grant Funds will be used only for eligible costs and expenses directly related to the school, child care, or other educational business, and no portion of the Grant Funds will be used for any normal profit or overhead of the church or other religious institution; (e) a financial business primarily engaged in the business of lending, such as a bank, finance company or factoring company; (f) a business engaged in any activity that is illegal under federal, state or local law; (g) a business of a prurient sexual nature, including a business which presents live performances of a prurient sexual nature or a business which derives directly or indirectly more than de minimis gross revenue through the sale of products or services, or the presentation of any depictions or displays, of a prurient sexual nature; (h) a business engaged in any socially undesirable activity or activity that may be considered predatory in nature such as rent-to-own businesses or check cashing businesses; (i) a business that restricts patronage for any reason other than capacity; (j) a speculative business, meaning a business for the sole purpose of purchasing and holding an item until the market price increases or other business principally engaged in risky activity for the chance of an unusually large profit, including but not limited to, (i) oil wildcatting, (ii) dealing in stocks, bonds, commodity futures, and other financial instruments and (iii) mining gold or silver in other than established fields; (k) a business that is affiliated (as such term is defined in 13 C.F.R. § 121.103) with another Applicant; or (l) a business, franchise or location of which the undersigned has already applied for and received a grant under the Program.

Yes

(8) I certify under penalty of perjury that any and all information provided by or on behalf of the Applicant, including without limitation the information contained in the Applicant’s grant application submitted for the Program and any and all information provided in support of Applicant’s application under the Program is and will be true and accurate in all material respects.

Yes

(9) I certify under penalty of perjury the Applicant acknowledges that the State of California, CalOSBA, GO-Biz and Orange County are each relying upon the certifications made in this document in addition to any other certifications made by the Applicant in connection with its application for the OC Microbusiness Grant Program. The Applicant further acknowledges and agrees that all certifications made by the Applicant in connection with the OC Microbusiness Grant Program are made in good faith.

Yes

(10) The Applicant agrees to the terms, conditions, and obligations of the Microbusiness COVID-19 Relief Grant Program and described under the section headings titled “Next Steps” and “Reporting Requirements” below.

Yes

Section 5: Certification by Authorized Business Representative

I hereby certify that I am an authorized representative of the business named above, with the authority to commit the business to legally binding contracts and agreements. I further certify that the information given as part of this application is true and accurate. I am aware that any false information or intended omissions may subject me to civil or criminal penalties for the filing of false public records and/or forfeiture of any funds approved through this program.

This application does not constitute a contractual agreement. If any portion of the application is approved, a formal agreement between parties will be executed to obligate funds for the approved expenditures. Activities may not start prior to the effective date of the agreement.

By signing this application, I certify that I am authorized to enter into an agreement with the Orange County that includes my representation, warranty and covenant that I am eligible to receive federal funding, my organization is in good standing with the State of California, Unemployment Insurance (UI) taxes and are in good standing and I agree to submit receipts for all purchases made with funding received and provide acceptable form(s) of valid government-issued photo ID (state, domestic, or foreign) and documentation that includes the owner’s name and may include but is not limited to the following: a local business permit or license, a bank statement, a tax return, a trade account and Third-party verification.

Signature (Please Enter First and Last Name)

Signature Date

Acknowledge Digital Signature