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Township of Franklin, NJ

techs@franklinnj.gov

475 Demott Lane, Somerset, NJ, 08873, US

732-873-2500

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CORONAVIRUS MICROENTERPRISE LOAN APPLICATION Form Continuation...co-owner section 4 

BUSINESS PROFILEEACH CO-OWNER MUST FILL OUT THEIR OWN FORM, SIGN AND SUBMIT

Business Address

SECTION 4 BUSINESS OWNER(S) INFORMATION AND ELIGIBILITY CONT.

Please list any individuals or other businesses that have ownership.

Complete for each:

1) proprietor or limited partner who owns more than 20% or more interest and each general partner, or 2) stockholder or entity owning 20% or more voting stock.

Owner Information 

Legal Full Name

% Ownership

US Citizen?

Owner Home Address

OWNER QUESTIONNAIRE

For the applicant business and each owner listed in Section 4 please respond to the following questions.

1. As the owner of the business, does your income fall below the limits specified under Owner Eligibility for Somerset County?

2. Has the business or the listed owner ever been involved in a bankruptcy or insolvency proceeding?

3. Does the business or listed owner have any outstanding judgements, tax liens, or pending lawsuits against them?

4. In the past year, has the business or listed Owner been convicted of a criminal offense committed that involved the distribution of any product or service that has been determined to be obscene by a court of competent jurisdiction?

5. Has the business or listed Owner ever had or guaranteed a federal loan or a federally guaranteed loan?

6. Is the business or the listed Owner delinquent on any federal taxes, direct, or guaranteed federal loans (SBA, FHA, VA, student, etc.)?

7. Does the listed Owner, owner’s spouse, or household member work for the Township of Franklin?

8. Is the applicant or the listed Owner currently suspended or debarred from contracting with the federal government or receiving federal grants or loans?

9. Is the listed Owner presently a) subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction; b) been arrested in the past six months for any criminal offense; c) or for any criminal offense- other than a minor vehicle Violation-1)been convicted, 2) plead guilty, 3) plead nolo contendere, 4) been placed on pretrial intervention, or 5) been placed on any form proof parole or probation (including probation before judgement)?

CARES ACT FUNDING SELF CERTIFICATION

The Department of Housing and Urban Development has provided direction that CDBG-CV funding is not to be awarded to any activity that has received, has been approved for, or  plans on applying for CARES Act funding from any other source.

As such, businesses that have received, been awarded or plans on applying for CARES Act Funds from any other source is not eligible for CDBG-CV funding.

Applicants are required to self-certify that they have not, and will not be, receiving CARES Act funding from any other source. The duplication of benefit from CARES  Act funds will cause the ineligibility of the applicant and require the immediate repayment of funding loaned and /or forgiven  from the Township of Franklin Coronavirus Microenterprise Loan Program.

I, We certify under penalty of perjury that the above named business and owners of the business have not received, have not been awarded, and will not be applying for CARES Act Funds from any other source, I, We are aware that there are penalties for willfully and knowingly giving false information on an application for federal funds, which may include immediate repayment of all federal funds received and/or precaution under the law. I, We understand that the information on this form is subject to review by Township staff and federal personnel as part of compliance monitoring.

SELF CERTIFICATION OF ABOVE STATEMENT

AGREEMENTS

I/We understand that this application will be used by the Township of Franklin to assess which resources might be appropriate and available for my/our business and that we are not guaranteed a loan or any form of financial assistance.

I/We understand that additional information and documentation may be required to assist the Township of Franklin in assessing which resources might be appropriate and available for my/our business and/or in making a determination regarding Micro Loan financial assistance. I/we will be advised in writing as to such required information and documentation.

I/We   authorize the Township of Franklin to verify information provided in this application, and additional information or documentation submitted, as needed to process and service Micro Loan financial assistance. This includes authorization for my/our insurance company, bank, financial institution, or other creditors to release to the Township of Franklin all records and information necessary to process this application.

I/We understand that if Micro Loan financial assistance is provided for my/our business that I/We will be required to certify compliance with applicable federal, state and/or local regulations that may include but not be limited to:

  • Project Assurances
  • Debarment/Suspension Certification
  • Environmental Certification
  • Non-Discrimination Certification
  • Person Completing Certifications
  • Family Size and Income Limits for Somerset County

I/We authorize the Township of Franklin as required by the Privacy Act, to release any information collected in connection with this application to Federal, state, local, tribal or nonprofit organizations for the purpose of assisting me with my/our Township of Franklin Micro Loan Fund application evaluating eligibility for additional assistance, notifying me of the availability  of such assistance.

I/We understand that if Micro Loan financial assistance is approved, additional information and/or documentation may be required prior to closing and funds disbursement.

I/We understand that only one person may submit this application on behalf of a business and that only one form may be submitted per business.

Acceptance of Conditions

By signing this intake form. I certify that all information submitted with this form is true and correct to the best of my knowledge, and that I will submit truthful information in the future.

Name of Signer

I agree to electronically sign and to create a legally binding request for Micro Loan Program funds between the Township of Franklin and the business I am authorized to represent.

Owner Signature

Choose how to sign

Are there additional owners?

Additional Business Owners MUST also certify and sign an agreement.

If additonal owners are present and able to complete signature form, Click here.  WARNING, THIS WILL OPEN A NEW BROWSER TAB

If additional owners are not present, please copy this link and send an email to each co-owner, so this form can be completed.

https://franklintwp.seamlessdocs.com/f/CDBG_COVID_LOAN2 

******WARNING, APPLICATION IS NOT CONSIDERED COMPLETE OR ACCEPTED UNTIL ALL BUSINESS OWNERS SIGNATURE FORMS ARE RECEIVED******

 

*You will LOSE your work if you:

  • Close the web browser BEFORE submitting
  • Close the tab BEFORE submitting