Complete Application TIME Application Type of Funding Applying for Micro Loan Forgivable Loan Program Person Submitting Application * Person Submitting Application First Name First Name Last Name Last Name Email Address Phone Number * Applicant's Address * Applicant's Address Applicant's Address Applicant's Address City City State/Province AlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming State/Province Zip/Postal Zip/Postal Applicant's Address Section I, Business Information arrowup6 Business Name Business Phone Business Website/URL Business Address Business Address Business Address Business Address City City State/Province State/Province Zip/Postal Zip/Postal Country AfghanistanAland IslandsAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBruneiBulgariaBurkina FasoBurundiCôte d'IvoireCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos (Keeling) IslandsColombiaComorosCongoCook IslandsCosta RicaCroatiaCubaCuracaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFalkland Islands (Malvinas)Faroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth KoreaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestinePanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarReunionRomaniaRussiaRwandaSaint BarthelemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint Martin (French part)Saint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint Maarten (Dutch part)SlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth KoreaSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTurks and Caicos IslandsTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUnited States Minor Outlying IslandsUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabwe Country Business Address How Long has your business been operating ? How did you hear about TIME Program What Business Banking Relationships do you have? Business Checking Loan Line of Credit Name of Business Owner #1 Name of Business Owner #1 First Name First Name Last Name Last Name % Ownership Black or Latino Owner Yes No Female ? Yes No Resides in Bartholomew County Yes No Name of Business Owner #2 Name of Business Owner #2 First Name First Name Last Name Last Name % Ownership Black or Latino Owner Yes No Female ? Yes No Resides in Bartholomew County Yes No How many full-time employees do you have Date Business Established Tax ID Number Please Upload a W9 form Drop a file here or click to upload Choose File Maximum file size: 516MB Are you in good standing with the Secretary of State or appropriate authority Yes No If Not Please Explain: Does your business participate in any of the Forms of Operation as listed below? Yes No Forms of Operation - Violates any U.S. federal or state law. - Owned/controlled by any government agency, public administration, political organization, or non-profit of any type, including labor groups. - Are engaged in any illegal activity (other than routine traffic violations). - Are primarily in the business of manufacturing, promoting, or selling diet aids, cannabis, gambling, tobacco (including tobacco-related equipment, such as e-cigarettes), firearms, or other weapons. - Are private clubs and businesses which limit the number of memberships for reasons other than capacity or related to applicable U.S. federal or state health guidelines. - Are principally engaged in teaching, instructing, counseling, or indoctrinating religion or religious beliefs, whether in a religious or secular setting. - Derive directly or indirectly more than the minimum gross revenue through the sale of products or services, or the presentation of any depictions or displays, of a sexual nature. - Are fraternities, sororities, or alumni groups. - Are owned by employees, officers, and directors of the Columbus Area Chamber of Commerce Foundation, Inc or the NAACP Columbus/Bartholomew Branch 3071 and any affiliated entities, and their respective immediate families (parents, spouse, children, siblings) or individuals residing in their household (whether or not related); - Are listed on the U.S. Department of the Treasury’s Sanctions List. How much have you invested in your business? Use the chart below to provide the source and use of funding. Source of Income Amount Utilization of Funds plus1 Add minus1 Remove Section II, Financing Information and Use of Funds arrowup6 Funds from this program may only be used for specific expenditures and in certain situations. Please review the allowable uses below: Allowable Expenses from Funding Rent, Operating capital for leasing space Cost of Goods Sold (food cost, materials) Marketing materials and advertising, including website development and servicing Licenses, dues, subscriptions Phone and Internet Supplies Insurance and/or utilities Staff salaries Equipment Leases and Software Payments, Equipment purchase (with or without installation costs) Purchasing inventory, supplies, accounting and inventory software, furniture, fixtures, and equipment Professional services, including legal, financial, and business consulting services, Costs of designing and retrofitting businesses to accommodate social distancing, including developing Covid-19-related policies Ineligible Use of Funding Pay off non-business debt, such as personal credit cards for purchases not associated with the business Purchase personal expenses such as buying a new family car or making repairs to a participant's home Purchase personal items or support other businesses in which the borrower may have an interest Distribute funds to a director or entity owned/controlled by a director Programs designed to influence - or fund through political contributions - a particular law, election or politically oriented cause, including voter registration and organized labor organizations and programs. Any program that results in indirect financial benefit to a specific individual, or an individual sponsorship related to fundraising activities. Religious programs or sectarian programs for religious purposes. How Much funding would you like to request through this program ? How do you plan to use the funding- Be specific: Visual Text If this funding was a loan (interest rate 2%) could you repay it over a four-year period? Yes, Likely Maybe Not Likely If Maybe or Not Likely, what concerns do you have? (Explain): Visual Text If yes, Potential Source of Repayment: Operating Profit Personal Income Other Explain :Other Explain : Section III, Legal and other Topics arrowup6 Are you a co-maker, endorser, or guarantor on any loan or contract? Yes No If Yes Please Explain:If Yes Please Explain: Do you currently have any business bills which are more than 30 days past due? Yes No If Yes Please Explain:If Yes Please Explain: Are you currently on Probation Yes No If Yes Please Explain:If Yes Please Explain: Section IV, Other Supporting Information: Please attach the Tax Forms, Business Plan, and Financial Plan arrowup6 If there is additional supporting information you would like to provide before your application is reviewed, please explain below. Visual Text Tax Forms Drop a file here or click to upload Choose File Maximum file size: 516MB Business Plans Drop a file here or click to upload Choose File Maximum file size: 516MB Financial Plans Drop a file here or click to upload Choose File Maximum file size: 516MB Section V, Certifications: arrowup6 Please read the following and sign the Application Form below. The information in this application is provided for the purpose of applying for funds under the TIME Program. The information is accurate to the best of my knowledge, and I understand if I falsify any information, it may make me ineligible for future support extended by programs of NAACP Columbus/Bartholomew Branch 3071. I understand that personal and/or business financial and credit information may be requested pursuant to this funding application, and I hereby give my consent for such information to be provided to the NAACP Columbus/Bartholomew Branch 3071, First Financial Bank, and/or Columbus Area Chamber of Commerce, or Columbus Area Chamber of Commerce Foundation representatives. I understand that the TIME program retains the sole discretion as to whether this funding application is approved, disapproved, or modified. I understand that it is my right to accept or decline the funding amount, rate, and terms approved through the program. I understand that I am required to meet with legal and accounting services offered by the TIME Program. I have included a complete, signed W9 form with this application. Name Name First Name First Name Last Name Last Name Date Signature Clear Submit If you are human, leave this field blank.
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