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Madison Heights COVID-19 Business Response Grant Program Application

  1. Madison Heights COVID-19 Business Response Grant Program Application
  2. Insert Facebook or Social Media Link
  3. Business Status*
  4. Please provide a brief paragraph outlining loss of income as a result of COVID-19 and your demonstrated need for this grant opportunity
  5. Please provide a brief explanation and an itemized list of how you intend to use these grant funds if awarded.
  6. January through March 2020
  7. January through March 2019 (Optional but strongly suggested)
  8. 1. Do you have outstanding Code enforcement actions? *
  9. 1. Have you received any other financial support or awarded any grants in response to COVID-19? *
  10. Explain any other financial support or grants received in response to COVID-19
  11. Applicant Certification:
    By signing this application, I certify that the statements herein are true, complete and accurate to the best of my knowledge. I also provide the required assurances* and agree to comply with any resulting terms if I accept an grant. I am aware that any false, fictitious, or fraudulent statements or claims may subject me to criminal, civil or administrative penalties. I understand the City may require assurances and receipts or proof of payments for grant expenditures.
  12. First, Last
  13. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.*
  14. Leave This Blank:

  15. This field is not part of the form submission.