Advance Your Business | Consulting Services & Grant

1. Microenterprise Owner Name*
2a. Phone*
3a. Microenterprise Name*
2b. Email*
3b. Microenterprise Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
4. Personal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Website
5. Race*
Pick One
- White
- Black / African American
- Asian
- American Indian / Alaskan Native
- Native Hawaiian / Other Pacific Islander
- Black / African American & White
- American Indian / Alaskan Native & White
- American Indian / Alaskan Native & Black / African American
- Other Multi-Racial
- Asian & White
6. Hispanic / Latino Ethnicity*
- Yes
- No
7. Female-Owned*
- Yes
- No
8. Military Veteran-Owned*
- Yes
- No
9. Disability-Owned*
- Yes
- No
10. Business Gross Annual Revenue:*
11. Number of employees including owner:*
Please enter a number from 1 to 5.
12. Business Status*
- New*
- Existing
*Business started and registered with the State during the timeframe support services were received.
13. Is your business:*
- Expanding
- Relocating
- N/A
14. Years in Business*
15. Business Type*
- Agriculture & Forestry
- Marketing, Technology and other Business Services
- Construction, Utilities, Contracting Services
- Childcare and Education Services
- Motor Vehicle
- Personal Services (personal care, entertainment, fitness, photography, cleaning, etc.)
- Real Estate & Housing
- Finance/Accounting, Insurance, and Taxes
- Transportation
- Food and Hospitality
- Healthcare services
- Other
Business Type (Other)
16. What was the impact of COVID-19 to your business?*
Check all that apply.
- My business had to shut down or reduce hours during the COVID-19 pandemic due to required closings, lack of childcare, etc.
- My business had to lay off staff due to the COVID-19 pandemic.
- My businesses experienced unexpected cost increases (such as personal protective equipment, retrofitting spaces to accommodate social distancing requirements, etc.) due to the COVID-19 pandemic
- Other
- Does not apply to me.
COVID-19 Impact (Other)
17. Has your business received any technical assistance or grant funding due to the impact of the Pandemic?*
- Yes, I have received technical assistance.
- Yes, I have received a grant.
- No, I have not received technical assistance or a grant.
Please describe the assistance or grant funding your business received.
18. Microenterprise owner income Guidelines:
Indicate the number of persons in the applicant's household*
Pick One
- 1
- 2
- 3
- 4
- 5
- 6
- 7
- 8+
Indicate the number of persons in the applicant's household*
Pick One
- $62,600 or less
- $71,550 or less
- $80,500 or less
- $89,400 or less
- $96,600 or less
- $103,750 or less
- $110,900 or less
- $118,050 or less
Supplemental Documents
Please provide a PDF of your most recent household income tax return which is used to verify program eligibility. If you are married and filed separately, please provide both tax returns.*
Accepted file types: pdf, Max. file size: 50 MB.
Please provide notification of your being in business on or before March 16, 2020. You can provide any of the following:*
You may provide any of the following: Limited Liability Company Articles of Incorporation Sole Proprietorship documentation Business Taxes from 2020 Other documentation that you were operating a business as of March 16, 2020
Accepted file types: pdf, jpg, png, gif, Max. file size: 50 MB.
Certification of Accuracy*
I hereby certify that the information included on this form is correct to the best of my knowledge and that such information may be subject to verification by representatives of the Washtenaw County and/or the United States Department of Housing and Urban Development for purposes of meeting the federal requirements of the Community Development Block Grant (CDBG) program.
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Advance Your Business Intake Form

18. Microenterprise owner income Guidelines:

Supplemental Documents

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