Klickitat County Small Business COVID Emergency Grant Program # 3
This is the official application for the Klickitat County Small Business COVID Emergency Grant program #3. . Along with this application you will need to fill out the Klickitat Small Business reimbursement form. You can find this along with an example form at https://www.klickitatcounty.org/1193/Covid-19
You will also need to have a W9 on file with the County Auditor. (forms can be found on the

Company Name *
Business Physical Address *
Ex. 127 West Court St, Golenddale, WA, 98620
Business Mailing Address (If different from above)
City *
Zip *
CEO/President or Owners Name *
Email Address *
Phone number (ex. 509-773-2410) *
Name of person filling this form out (if different from above)
Email address of person filling out this form (if different from above)
Washington State UBI Number *
What Year was the Business Established *
Has the business been in operation for 1 year as of March 1, 2020 *
Is the business?
Is the Business Certified with the OMWBE (Office of Minority and Women's Business Enterprise) *
Race/Ethnicity of business ownership, please Check one of the following below (response is optional, but encouraged) *
What industry sector is the business in *
Number of Full time Employees as of the date you submit this grant application. *
Maximum number of employees in the past year (include- seasonal, part-time, full time, owners *
Have you had to lay off or furlough employees as a result of Covid-19 (business owners count as employees) *
When did the impacts of the required closures under Governor Inslee's Stay at Home Order, Stay Healthy Proclamation begin for your business? *
Was the business compelled to close at any time since March 1, 2020 in order to comply with required closures? *
Has compliance with applicable COVID regulations affected business costs and/or revenue generation? *
Total Estimated Revenue Impact to date *
Has your business received COVID- related funding from a state, county, federal government, or private (e.g. business interruption insurance) source in relation to COVID-19? *
Businesses may not be reimbursed by multiple funders for the same cost (double dipping), and this principle also applies to any recipients of CARES funding. No duplicate payments or supplanting of other costs are allowed.
Has the business received funds through the Paycheck Protection Program *
Has the business Received a Working Washington Small Business Emergency Grant *
Has the business received a loan through the SBA Economic Injury Disaster Loan Program? *
Has the business Received the Economic Injury Disaster Loan Advance (grant)? *
Has the business applied for COVID-19 related grant/loan programs and been unsuccessful? *
What is the likelihood of the business closing permanently due to Covid-19 *
Are the current conditions for your business *
Amount of grant funds requested (please ensure this is equal to the amount requested for reimbursement in the Reimbursement Form- up to $10,000) Total. *
If you have been awarded funds either through the Working Washington or Klickitat County Small Business Emergency Grant program your cumulative award between the grants is capped at $10,000. If you have not been awarded funds under either of these grant programs you can apply for up to $10,000.
Eligibility Cost Test- For each of the expenses listed on the Reimbursement Form, can and will you attest that all of the following statements are true: *
The expenses is connected with to the COVID-19 Emergency - The expense is necessary to to continue business operations- The expenses is not filling a shortfall in government revenues (i.e. pay taxes, licenses, state, county, federal, and/or city fees) - The expenses is not funded by any other funder, whether private (e.g. business interruption insurance), federal, County, or City- The business wouldn't be requesting assistance with expenses if they had not been impacted by COVID-19.
Expense Documentation- *
Can you provide clear documentation and proof of payment by the business for each expense listed on the Reimbursement Form (e.g. for lease reimbursement provide copy of the lease in the business name and a bank statement, receipt, or copy of cashed check?
Please give an overview of your business- 500 words max. *
What is the public benefit of your business being selected for the Small Business Grant Program - Click all that apply *
Please describe how your business is involved with your community *
Other relevant information about your business, your loss of business, how these funds will help your stay in business
Additions comments not addressed above
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