COVID-19 Emergency Relief Loan Fund Program Application

Legal form of Business*
S CorporationJoint VentureFor-ProfitC corporationGeneral PartnershipSole ProprietorshipLimited Liability CompanyLimited Partnership

Working capital - current payroll expenses*

Working capital - current rent/mortgage expenses*

Working capital - all other current expenses*

Working capital - delinquent payroll expenses*

Working capital - delinquent rent/mortgage expenses*

Working capital - All other delinquent expenses (list)*

Acquisition of equipment or vehicle*

Facility improvements (due to COVID-19)*

Other (Explain)*

TOTAL*

[calculator total-use-of-loan-proceeds Prefix:$ "current-payroll-expenses + current-rent-mortgage-expenses + other-current-expenses + delinquent-payroll-expenses + delinquent-rent-mortgage-expenses + other-delinquent-expenses + acquisition-of-equipment-vehicle + facility-improvements-COVID-19 + other-expenses"]

Gender? MaleFemale

Applicant 2

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Gender? MaleFemale

Applicant 3

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Gender? MaleFemale

IF MORE ROOM IS NEEDED TO LIST OWNERS, ATTACH A SEPARATE SHEET WITH THE ABOVE INFORMATION

The applicant’s principal place of business is in Maryland

Has been economically affected by the COVID-19 crisis.

The applicant was established on or prior to January 1, 2019

The person(s) holding a majority (at least 51%) of the ownership interest in the applicant must have a minimum credit score of 550

The applicant has not received a COVID-19 relief loan from the State of Maryland

The applicant is in good standing in its state of incorporation and is qualified to do business in Maryland if it is a foreign corporation

The applicant either does not have or is not currently in default or delinquent on any loan or payment obligation it has with the Maryland Department of Commerce or any other state of Maryland agency (If unchecked, please explain and provide current status-include attachment, if necessary)

been convicted of a criminal offense other than traffic violation(s)?*

been a debtor in bankruptcy or insolvency proceedings?*

been a party to any pending litigation?*

had a judgment entered that has not been satisfied?*

has any delinquent or outstanding taxes?*

Are any of the aforementioned parties subject to any outstanding liens that may lead to a judgment(s)?*

Does the company or its owners have any liens, judgments and/or contingent liabilities that are not disclosed elsewhere in the application package?*

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Completed the entire application and signed pages 7 & 8

Completed and signed IRS Form W-9

Financial statements (income statement and balance sheet) or tax returns for 2018 and 2019

COVID-19 Impact Summary (see Section 6 of this application) and one or more of the following:

1. Interim financial statements (income statement and balance sheet) for the most recent fiscal period but, in any case, for the fiscal period ending no earlier than May 31, 2020
2. Delinquency notices or emails that reflect the applicant’s inability to pay employees, pay rent or mortgage, pay suppliers or make loan payments, etc. in 2020
3. Evidence of increased costs related to COVID-19 prevention measures such as invoices, cancelled checks, purchase orders, contracts, etc.
4. Evidence of disrupted supply chain or network leading to shortage of critical inventory or materials
5. Other evidence of business disruption due to COVID-19

Resumes for all individuals owning 20% or more of the applicant

Financial projections for next six (6) months with related assumptions

Insurance Certificates or Binders for facilities, inventory, Worker’s Compensation, and general liability (if loan request is $100,000 or greater)

List all other reporting entity Unemployment Insurance ID Numbers

AUTHORIZED REPRESENTATIVE: I HEREBY AFFIRM THAT I am the and a duly authorized representative of and that I possess the legal authority to make this Affidavit on behalf of myself and the business for which I am acting.

CERTIFICATION OF CORPORATION REGISTRATION AND TAX PAYMENT: I FURTHER AFFIRM THAT:
(1) The business named above is a [ ]"] formed in MarylandOther state and registered in accordance with the Corporations and Associations Article, Annotated Code of Maryland, and that it is in good standing and has filed all of its annual reports, together with filing fees, with the Maryland State Department of Assessments and Taxation, and that the name and address of its resident agent filed with the State Department of Assessments and Taxation is:

(2) Except as validly contested, the business has paid, or has arranged for payment of, all taxes due all government entities including the State of Maryland and has filed all required returns and reports with the Comptroller of the Treasury, the State Department of Assessments and Taxation, the Department of Labor, Licensing and Regulation (DLLR), and all other taxing authorities, as applicable, and will have paid all withholding taxes due to the State of Maryland and all other government entities prior to final settlement.

AFFIRMATION REGARDING BRIBERY CONVICTIONS: I FURTHER AFFIRM THAT neither I, nor to the best of my knowledge, information, and belief, the above business, (as is defined in §16-101(b) of the State Finance and Procurement Article of the Annotated Code of Maryland), nor any of its officers, directors, or partners, nor any of its employees directly involved in obtaining or performing contracts with the public bodies (as is defined in §16-101(f) of the State Finance and Procurement Article of the Annotated Code of Maryland), has been convicted of, or has had probation before judgment imposed pursuant to Article 27, §641 of the Annotated Code of Maryland, or has pleaded nolo contendere to a charge of, bribery, attempted bribery, or conspiracy to bribe in violation of Maryland law, or of the law of any other state or federal law, except as follows: [indicate the reasons why the affirmation cannot be given and list any conviction, plea, or imposition of probation before judgment with the date, court, official or administrative body, the sentence or disposition, the name(s) of the person(s) involved, and their current positions and responsibilities with the business]:

AFFIRMATION REGARDING OTHER CONVICTIONS: I FURTHER AFFIRM THAT neither I, nor to the best of my knowledge, information, and belief, the above business, nor any of its officers, directors, or partners, nor any of its employees directly involved in obtaining or performing contracts with public bodies, has:

1. been convicted under state or federal law of a criminal offense incident to obtaining, attempting to obtain, or performing a public or private contract, fraud, embezzlement, theft, forgery, falsification or destruction of records, or receiving stolen property;
2. been convicted of any criminal violation of a state or federal antitrust statute;
3. been convicted under the provisions of Title 18 of the United States Code for violation of the Racketeer Influenced and Corrupt Organization Act, 18 U.S.C. §§1341, et seq., or Mail Fraud Act, 18 U.S.C. §§1341, et seq., for acts arising out of the submission of bids or proposals for a public or private contract;
4. been convicted of a violation of the State Minority Business Enterprise Law, Section 14-308 of the State Finance and Procurement Article of the Annotated Code of Maryland;
5. been convicted of conspiracy to commit any act or omission that would constitute grounds for conviction or liability under any law or statute described in subsection (a), (b), (c), or (d) above;
6. been found civilly liable under a state or federal antitrust statute for acts or omissions in connection with the submission of bids or proposals for a public or private contract; or
7. admitted in writing or under oath, during the course of an official investigation or other proceeding, acts or omissions that would constitute grounds for conviction or liability under any law or statute described above,

except as follows: [indicate reasons why the affirmations cannot be given, and list any conviction, plea, or imposition of probation before judgment with the date, court, official or administrative body, the sentence or disposition, the name(s) of the person(s) involved and their current positions and responsibilities with the business, and the status of any debarment]:

AFFIRMATION REGARDING DEBARMENT: I FURTHER AFFIRM THATneither I, nor to the best of my knowledge, information, and belief, the above business, nor any of its officers, directors, or partners, nor any of its employees directly involved in obtaining or performing contracts with public bodies, has ever been suspended or debarred (including being issued a limited denial of participation) by any public entity, except as follows: [list each debarment or suspension, providing the date of the suspension or debarment, the name of the public entity, the status of the proceedings, the name(s) of the person(s) involved and their current positions and responsibilities with the business, the grounds for the debarment or suspension, and the details of each person’s involvement in any activity that formed the grounds for the debarment or suspension]:

AFFIRMATION REGARDING DEBARMENT OF RELATED ENTITIES: I FURTHER AFFIRM THAT:

1. The business was not established to, nor does it operate in a manner designed to, evade the application of or defeat the purpose of debarment pursuant to §§16-101, et seq., of the State Finance and Procurement Article of the Annotated Code of Maryland; and
2. The business is not a successor, assignee, subsidiary, or affiliate of a suspended or debarred business, except as follows: [indicate the reasons(s) why the affirmations cannot be given without qualification]:

SUB-CONTRACT AFFIRMATION: I FURTHER AFFIRM THAT neither I, nor to the best of my knowledge, information, and belief, the above business, has knowingly entered into a contract with a public body under which a person debarred or suspended under Title 16 of the State Finance and Procurement Article of the Annotated Code of Maryland will provide, directly or indirectly, supplies, services, architectural services, construction related services, leases of real property, or construction.

ACKNOWLEDGMENT: I ACKNOWLEDGE THAT this Affidavit is to be furnished to COMMERCE and may be distributed to units and agents of (1) the State of Maryland, (2) counties or other subdivisions of the State of Maryland, (3) other states and their subdivisions, and (4) the federal government. I further acknowledge that this Affidavit is subject to applicable criminal and civil laws of the United States and the State of Maryland and that nothing in this Affidavit or any agreement resulting from the submission of this application shall be construed to supersede, amend, modify, or waive, on behalf of the State of Maryland or any of its units or agents, the exercise of any statutory right or remedy conferred by the Constitution and the laws of Maryland with respect to any misrepresentation made or any violation of the obligations, terms, and covenants undertaken by the above business with respect to (1) this Affidavit, (2) the proposed contract, and (3) other Affidavits comprising part of the proposed contract.

In Accordance with Executive Order 01.01.1983.18, the Department of Commerce (the Department” or “COMMERCE”) advises you as follows regarding the collection of personal information:

Certain personal information requested by the Department or its Agents, including Meridian Management Group, Inc., is necessary in determining your eligibility. Failure to disclose this information may result in the denial of these benefits or services. Availability of this information for public inspection is governed by the provisions of the Maryland Public information Act, State Government Article, Sections 10-611 et seq. of the Annotated Code of Maryland. This information may be disclosed to appropriate staff of the Department, public officials, and auditors of the Department’s affairs for purposes directly connected with the processing of your application and the administration of the program for which its use is intended. This information is routinely shared with State, federal, and local government agencies. Information regarding job creation and retention may be shared with the public. You have the right to inspect, amend, or correct personal records in accordance with the Maryland Public Information Act.

Certification: All information in this application and in the attached exhibits, attachments, and addendums is true and complete to the best of my/our knowledge, information, and belief. I/We agree to pay for the cost of any surveys, title or mortgage examinations, credit reports, lien searches, appraisals, etc. that are necessary for consideration of this application. Further, I/we agree not to engage in employment practices that deny equal employment rights to persons by reason of (i) political or religious opinion or affiliation, marital status, race, color, creed, or national origin; (ii) sex or age, except when sex or age constitutes a bona fide occupational qualification; or (iii) physical or mental disability of a qualified individual with a disability. I/we agree to comply with the State’s policy on maintaining a drug and alcohol free workplace. I hereby authorize all involved in the financing of this project to exchange freely, without further authorization and consent, any financial information and reports provided in connection with this application and the processing of this loan request.

Obligation to Report Change in Financial Position: Each of the undersigned agrees to notify you immediately and in writing of any change in name, address, or employment and of any material adverse change in (1) any of the information contained in the statement, (2) the financial condition of any of the undersigned, or (3) the ability of any of the undersigned to perform its (or their) obligations to you.

This form is for gathering statistical data only. This form will be separated from the application and the information provided in it will not be a part of the application approval process. Furnishing this information is voluntary; failure to do so will have no effect on the approval of the requested financial assistance.

Is respondent the APPLICANT and/or RECIPIENT (or FACILITY USER)

If Respondent is a business organization:

If Respondent is a business owned and controlled primarily by individuals who are identified in any of the following categories, please check all the categories that apply:

Female
Of Hispanic or Latino origin
American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or other Pacific
Islander White
Veteran

Is the Respondent a State/Federal/Other certified Minority Business Enterprise?

Respondent is a publicly held entity or other organization not classifiable as owned by individuals of a particular gender, race, ethnicity, or veteran status.

Is the Respondent Female?

Is the Respondent of Hispanic or Latino origin?

Is the Respondent a Veteran?

American Indian or Alaska Native

Asian

Black or African American

Native Hawaiian or other Pacific

White