DECD: Small Business Express Program - Financial Assistance Application

 

STATE OF CONNECTICUT - SMALL BUSINESS EXPRESS PROGRAM

Financial Assistance Application

 

Instructions:  Complete this form and submit under separate cover the highlighted areas, if applicable, on line, via email or mail to:  Michelle Peters, DECD, 505 Hudson Street, Hartford, CT 06106, Michelle.Peters@ct.gov
 

Section One: Program (Please check below the component you are applying to)

Small Business Express Revolving Loan Fund (10k-100k)
Small Business Express Job Creation Incentive Loan (10k-300k)
Small Business Express Matching Grant (10k-100k)


Section Two: Applicant Information

Applicant (Recipient of Funds):
Address:
City:
State:
Zip:
Applicant Website:
Federal ID Number:
State Tax Registration Number:
Project Location:
County:

Contact Information:  Name

                              Title

                              Phone

                              Fax

                              Email

Business Industry:
NAICS Code:
Minority Owned: No Yes    If yes, %
Woman Owned: No Yes    If yes, %
Veteran Owned: No Yes

International Exporting:

No Yes
Applicant Structure (S-Corp, LLC, corporation, partnership, etc.):

Date Established:

State of Incorporation:

Employment: (CT based jobs)  

Existing jobs: 

  Full Time (Registered with DOL)        Part Time
    Number of hours per week for full time

New Jobs:

  Full Time                                       Part Time

 

  Anticipated timeframe for new jobs

Ownership Information (Submit under separate cover): (1) List of name(s), (2) Title(s), (3) Address(es), (4) % of ownership, (5) Identify and list owners by % of women-owned or % of minority-owned if applicable; (6) Soc. Sec. # and/or Federal ID#.
 

Company Status:

  • Does the applicant have any delinquent State, Federal or Local Taxes? (If yes, submit explanation under separate cover)
No Yes
  • Do any owners/officers have any personal tax issues? (If yes, please provide an explanation.)
No Yes
  • Has the applicant or its owners ever filed for bankruptcy? (If yes, submit explanation under separate cover.)
No Yes
  • Has the applicant or its owners ever been convicted of a felony?
No Yes
  • Does the applicant or its owners have any outstanding, pending or anticipated litigation, environmental, OSHA or other issues outstanding? (If yes, submit explanation under separate cover,)
No Yes
  • Has the applicant received prior state financial assistance from other government agencies or departments?
No Yes
 

Section Three: Assistance Request Information

 

EXP Grant Amount Requested: $      EXP Loan Amount Requested: $

 

Brief Project Description and Use of Funds Request (See procedures for eligible uses and submit under separate cover.):

 
*Please note: At the discretion of the Commissioner, financial assistance may require collateral.

 

Section Four: Additional Information (Please provide the following information under a separate cover)

 

  • Last three fiscal years of accountant-prepared financials, including notes. If not available please provide tax returns and internal financials (balance sheet and income statement) for this period.
  • Applicant Structure Documentation (e.g. Articles of Incorporation, proof of registration to conduct business in Connecticut, etc.)
  • Project Description (include rationale for budgeted cost estimates, economic impact, measurement of impacts)
  • Business Plan (company history, products and services, description of market and competition, revenue forecasts)


Section Five: Certification


It is hereby represented by the undersigned to the State of Connecticut including but not limited to the Department of Economic and Community Development to consider the financial assistance requested herein, that to the best of my knowledge and belief no information or data contained in the Application or in the attachments are in any way false or incorrect and that no material information has been omitted, including the financial statements. The undersigned agrees that banks, credit agencies, the Connecticut Department of Labor, the Connecticut Department of Revenue Services, the Connecticut Department of Energy and Environmental Protection, and other references are hereby authorized now, or anytime in the future, to give the State of Connecticut including but not limited to the Department of Economic and Community Development any and all information in connection with matters referred in this Application, including information concerning the payment of taxes by the applicant, its owners, and executives. In addition, the undersigned agrees that any funds that may be provided pursuant to this Application will be utilized exclusively for the purposes represented in this Application, as may be amended. False statements made in the preparation and submission of this applicant and related materials are punishable as a Class A Misdemeanor under Connecticut General Statutes 53a-157b.
 


Section Six: Public Announcement


Please be advised that your company and your job creation/retention project may be highlighted in a press release issued by the State.  Company proprietary or trade secret information WILL NOT be disclosed.  If you would like additional information concerning this, please contact DECD.

By submitting this document I,
  (insert Authorized Name/Title) certify and agree to the above.