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SAFE (Safety & Freedom Enhancement) Program Application

  1. Application period is scheduled to close on December 31, 2020, at 5:00PM PDT.

    PLEASE NOTE: Your application MUST be completed and submitted prior to the deadline as this form will deactivate at 5:01 PM on December 31st.

  2. BUSINESS CONTACT INFORMATION

  3. Is the Mailing Address above for a Home or Office?*

  4. BUSINESS INFORMATION

  5. Is your Business Part of a Chain? (More than 5 locations)*

  6. Is Your Business a Franchise?*

  7. Has the Business Filed for Bankruptcy Within the Past 3 years?*

  8. Does the Business Have Outstanding Liens or Judgements? * (Include UCC liens, Mechanics liens, Tax liens, etc.)*

  9. THE COVID-19 IMPACT

  10. Is the Business Considered Essential or Non-Essential Per Governor Newsom’s Shelter-In-Place Order?*

    (Review the Essential/ Non-Essential Business List here: ( https://covid19.ca.gov/stay-home-except-for-essential-needs/ )

  11. Was the business open during the Shelter in Place order?*

  12. USE OF THE SAFE GRANT FUNDS

  13. SUPPORTING DOCUMENTATION

  14. • Copy of Current FBN
    • Proof of Liability Insurance
    • Proof of Workers Compensation Insurance
    • 2019 P&L, Balance Sheet, CPA Documents, or Other Financial Records showing proof of business revenue
    • 2020 P&L, Balance Sheet, CPA Documents, or Other Financial Records showing proof of business revenue
    • 2019 Payroll documentation (IRS Form 941)
    • 2020 Payroll documentation (IRS Form 941)
    • Copies of current utility bills
    • Copies of current lease/ mortgage

    Additional documentation which may be required to verify your request:
    • Any additional documentation needed to support the application
    • Tax returns – IRS Form 4506T (signed)
    • Schedule of Payables
    • Cash Flow Statements
    • Debt Schedules

    Acceptable file types: pdf, doc, docx, txt, rtf, jpg, jpeg, gif, tif, tiff, png, csv.

  15. CERTIFICATIONS AND SIGNATURE

    Note: All of the following statements must be checked in order to be considered for the SAFE Grant

  16. I confirm that my business is engaged in activities that are regulated within Mariposa County and I/we have a permit associated to that regulation*

  17. I acknowledge and agree that, to fullest extent permitted by law, I shall forever RELEASE, HOLD HARMLESS, DISCHARGE and AGREE TO DEFEND AND INDEMNIFY, the COUNTY of MARIPOSA, the Mariposa County Board of Supervisors, their officers, directors, all employees therein, attorneys, agents, volunteers, independent contractors, and any and all subcontractors, from any liabilities, claims, demands, or causes of action that they may hereafter have, without limitation, for personal, bodily, or mental injuries, property damages, economic losses, attorney’s fees, or any other type of injury or damage arising out, resulting from, or in connection with, this application.*

  18. I agree to provide additional documentation upon request to help verify the economic hardship suffered as a result of the COVID-19, including tax returns, financial statements, and other financial data.*

  19. I agree to document and report economic impact achieved as a result of the program, including but not limited to, supplies purchases and all additional expenses.*

  20. I acknowledge that while the application period is scheduled to conclude at 5:00PM on June 30, 2020, Mariposa County, at its sole discretion, reserves the right to terminate the application submission and/ or processing period at an earlier date/ time depending on the number of applications received and overall available funding for the program.*

  21. I hereby certify that the information provided, contained herein and attached hereto is accurate and correct to the best of my knowledge.*

  22. Use of Digital Signature*

    By checking the "I agree" box below, you agree and acknowledge that:
    1) your application will not be signed in the sense of a traditional paper document,
    2) by signing in the alternate manner below, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and
    3) you may still be required to provide a traditional signature at a later date.

  23. Leave This Blank:

  24. This field is not part of the form submission.