ARPA Business Application | United Way of the Coastal Empire

Owner/Partner/Chairperson/Authorized Member Submitting Application
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Certifications & Acknowledgements
I certify that this American Rescue Plan assistance is not duplicative of other public or private funding received.(Required)
- Yes
I certify that this American Rescue Plan assistance will be used for payroll, rent, mortgage, utility, or COVID-19 mitigation efforts associated with the business/company.(Required)
- Yes
I certify that the business/company will make consistent and assertive efforts to continue operations through March 1, 2023.(Required)
- Yes
I certify that I am not aware of any conflicts of interest that exist between the business/company, myself, or any other person who is an employee, agent, consultant, officer, elected official, or appointed official of Liberty County and is in the position to participate in a decision-making process or are responsible for the administration or oversight of the Small Business Recovery Program.(Required)
- Yes
I acknowledge that, if selected, a formal agreement will be signed with Liberty County.(Required)
- Yes
I acknowledge that, if selected, the program requires that a Lawful Presence Affidavit and IRS Form W-9 be completed in order to receive payment.(Required)
- Yes
I understand that making false statements, concealing information, submitting altered documents, utilizing funds for ineligible purposes, or similar actions are considered fraudulent and may result in repayment of the grant award or other legal action. I also understand that failure to submit timely and adequate documentation may result in repayment of funds received.(Required)
- Yes
I certify that I will provide a nine (9) month financial report on the use of the funds.(Required)
- Yes
Authorized Signature
By signing and submitting this document, I certify that I am either a sole proprietor, general partner, member, executive director, or chairman of the aforementioned LLC/Corporation/Nonprofit. Further, I have made the necessary notifications and received the appropriate authorization to submit an application on behalf of the business/company. I attest that I have thoroughly reviewed the application. The information presented is true and accurate.
Name(Required)
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Signature(Required)
Date(Required)
MM slash DD slash YYYY
THE DEADLINE TO SUBMIT AN APPLICATION IS APRIL 15, 2022 AT 5:00 PM
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American Rescue Plan

Owner/Partner/Chairperson/Authorized Member Submitting Application

Business Information

Additional Business Information

Required Attachments

Optional Attachments

Certifications & Acknowledgements

Authorized Signature

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