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Page 2 of 2 <br /> <br /> <br />When did the impact start? Start Date: / ___ <br /> <br />Please estimate your revenue impact comparing March to September 2019 to March to Current 2020 : <br />Additional comments about revenue impact: <br />Likelihood of Permanently <br />Closing the non-profit <br /> <br /> High Medium Low Business Closed Due to Governor’s Directive <br /> <br />Number of potential jobs lost _ <br />W ill this grant help retain jobs? If so, how many? <br />Has the company received any state, federal, or other funding? If yes, please list the type of funding received, Federal or State, the entity who provided you funding, <br />how much funding was provided, and what did your business pay for when utilizing this funding? (documents may be requested) If not, enter N/A. <br /> <br /> <br /> <br />*Non Profit may not be reimbursed by multiple funders for the same cost (double-dipping), and this principle also applies to any recipients of CARES funding: No duplicate payments or supplanting of other <br />costs are allowed. Whereas, if it comes forward funding has been received for the same invoices, bills, etc. the funding would need to be returned and future funding for your business could be at risk. <br />EXPLANATION OF USE OF FUNDS <br />Explain how funds will be used to help the non-profit. This information can help Commerce ensure that the expenses proposed are eligible for reimbursement. <br />Applications without a list of proposed expenses will be considered incomplete. <br /> <br />(please circle answer) Is the expense connected to COVID-19 emergency? Yes No Is the expense necessary to continue non-profit operations? Yes No <br /> <br />The expense is not filling a short fall in government revenues, (i.e. taxes, licenses, state, county, federal and/or city fees) Yes No <br /> <br />Note: Non-Profit wouldn’t be requesting assistance with expenses if they had not been impacted by COVID-19. <br /> Self-Attest Certification: The expense is not filling a short falling government revenues, (i.e. taxes, licenses, state, county, federal and/or city <br />fees. The nonprofit will self-attest that the expense is not funded by any other funder, whether private, State or Federal. The business wouldn’t be <br />requesting assistance with expenses if they had not been impacted by COVID-19. _______(initial) <br /> <br />EMPLOYMENT INFORMATION <br />Average Employee Salary: <br />Benefits Paid:  Yes No <br />Is the applicant’s LNI <br />account current?  Yes No Not Sure <br />You may look up the businesses online at https://secure.lni.wa.gov/verify/ <br />What measures the company is <br />already taking or trying to take to <br />support employees during the <br />pandemic? <br /> <br />ADDITIONAL INFORMATION <br />Currently, is the company facing any pending litigation or legal action? <br /> <br /> <br /> <br />Has the company had any state compliance/regulatory issues within Washington or another state you are or have done business in?