1Contact Info2Disaster/Loss Info3Insurance Info4Other Assistance5Certification I am applying for:* Business Grant Individual Contact InformationName* First Last Home Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Mailing Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Primary Phone*Cell/Other PhoneEmail* The best way to contact me is via:* Telephone Email Salon Contact InformationSalon Name* Salon Owner's Name* Salon Address* Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Salon Phone*Salon Website* My relationship to this salon is:* Salon Owner I've owned this salon for ___ years. Disaster and Loss InformationFollowing is a summary of the losses I incurred:Property Damage Property Damage Property Damage Loss AmountAmount of Loss or DamageProperty Destruction Property Destruction Property Destruction Loss AmountAmount of Loss or DamageProperty Loss of Use Property Loss of Use Property Loss of Use Loss AmountAmount of Loss or DamageBusiness Interruption Business Interruption Business Interruption Loss AmountAmount of Loss or DamageOther disasters or lossesClick (+) to add more.Type of Disaster or Loss Amount of Loss or Damage Insurance InformationPlease provide information about insurance funds you have received.Property - Salon Property - Salon Property - Salon Funds ReceivedFunds ReceivedProperty - Salon Claim Submitted? Claim Submitted? Property - Home Property - Home Property - Home Funds ReceivedFunds ReceivedProperty - Home Claim Submitted? Claim Submitted? Renter's Renter's Renter's Funds ReceivedFunds ReceivedRenter's Claim Submitted? Claim Submitted? Business Interruption Business Interruption Business Interruption Funds ReceivedFunds ReceivedBusiness Interruption Claim Submitted? Claim Submitted? Other insurance typesClick (+) to add more.Type of Assistance Funds ReceivedClaim Submitted? Claim Submitted Other AssistancePlease provide information about types of assistance you have applied for or received.7(a) PPP Loan Date AppliedDate Applied MM slash DD slash YYYY 7(a) PPP Loan StatusStatus (if no funds received) Pending Denied 7(a) PPP Funds ReceivedFunds ReceivedSBA Emergency Loan SBA Emergency Loan SBA Emergency Loan Date AppliedDate Applied MM slash DD slash YYYY SBA Emergency Loan StatusStatus (if no funds received) Pending Denied SBA Emergency Loan Funds ReceivedFunds ReceivedUnemployment Benefits Unemployment Benefits Unemployment Benefits Date AppliedDate Applied MM slash DD slash YYYY Unemployment Benefits StatusStatus (if no funds received) Pending Denied Unemployment Benefits Funds ReceivedFunds ReceivedAny other assistance?Click (+) to add more.Type of Assistance Date Applied MM slash DD slash YYYY Status (if no funds received) Pending Denied Funds Received CertificationI certify that I have suffered losses from an unexpected emergency which has affected me and/or the salon or spa with which I am affiliated. I certify that the information contained in this application is true and complete and that any fraudulent representations and omissions may result in the denial of grant assistance. I further understand and agree that in the event I am awarded a grant based on such fraudulent representations or omissions, I will be asked to and expected to immediately return any grant money awarded to me. I understand that submitting this Grant Application does not entitle me to receive a grant award, and that The Salon and Spa Relief Fund, Inc., its Board of Directors, and/or its Grant Committee shall determine in its sole and absolute discretion whether I qualify to receive grant assistance. NEXT STEP: After you hit the submit button, you will need to use the secure portal to upload A) a copy of your 2019 Federal Tax Return (2018 if 2019 not yet filed) and B) a statement with detailed information about losses including: (1) itemization of amount of each type of loss (property damage, income loss, etc.); (2) amount of total loss (or estimate); (3) dates of business closure and anticipated time salon will be closed (if not currently open); (4) short term and long term plans for recovering from this disaster.Signature* First Last Date* MM slash DD slash YYYY
