Small Business Grant Program Form | The City of Lakewood, Ohio

I. Business Information

Business Name

Type (Existing, Start-Up, Relocate to Lakewood)

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Year Established

Website

Current Avg Monthly Payroll ($)

2017 Gross Revenue

# Full-Time Employees

# Part-Time Employees

50%+ Minority (MBE)/Female (FBE) Owned?

MBE
FBE

Business Description

II. Applicant/Owner Information

Name

First Last

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone

Email

Other(s) with 10%+ Ownership (if any)

III. Project Information

Project Description

Total Project Cost (estimated)

IV. Preferred Lenders

Lender #1

Lender #2

Lender #3

Proposed Use of Performance Grant (e.g. construction, equipment, working capital, property acquisition, etc...)

Number of New Full-Time New Jobs Created by Funded Project

Number of New Part-Time New Jobs Created by Funded Project

Number of Existing Full-Time Jobs Retained by Funded Project

Number of Existing Part-Time Jobs Retained by Funded Project

I certify the information provided in this application is true and accurate and I understand participation in the Performance Grant Program requires 1) a 10% owner equity injection; 2) completion of technical assistance provided by a Small Business Development Center (SBDC), 3) creation of new payroll positions, 4) 75% project financing via an SBA loan issued from a participating lender

Name

Date

Please contact Dan Wyman @ 216-529-7680 or daniel.wyman@lakewoodoh.net for additional information