Form Center

SAFE (Safety & Freedom Enhancement) Program Application

2. 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.

   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.

4. Program Summary Criteria, Eligibility, and Process
   Full Program Details (PDF)

6. BUSINESS CONTACT INFORMATION

8. Legal Name (Entity Name or First Name, Last Name, if Individual)*

10. Business Name or DBA*

12. List all DBA(s) Being Used.

14. Ownership Type (Sole Proprietor, Partnership, LLC, Etc.)*

16. List the names of All Owning Partners and/ or Board Members*

18. Physical Business Address*

20. Mailing Address*

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

    1. Home
    2. Office

24. Applicant’s Name*

26. Applicant’s Relationship to the Business?*

28. Applicant’s Phone Number*

29. Applicant’s E-mail*

31. Business Phone Number*

32. Business E-mail*

34. Business Website

36. BUSINESS INFORMATION

38. Federal Employment Identification Number (FEIN), Social Security Number (SSN) or Tax Identification Number (TIN)*

40. What is the Business’ 8-Digit State Payroll/ DE9(c) Number? (If Unknown, Call EDD at (888) 745-3886 to Obtain)*

42. What Best Describes Your Industry Sector?*
    -- Select One --Restaurants (dine in, food truck)Fitness or Health Center (gyms, dance/karate studios, yoga centers)Entertainment Venue (banquet hall, movie theater, convention center)Personal Care/Grooming (spa, nail salon, beauty/barber shop)Retail Trade (clothing stores, vintage shops, specialty shops)Construction (remodeling, renovations, contractors)Other (If other, please tell us about it in the next field)

43. Please Explain the "Other Sector"

45. How Long Has Your Business Been Continuously Operating in Mariposa County?*

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

    1. Yes
    2. No

49. Is Your Business a Franchise?*

    1. Yes
    2. No

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

    1. Yes
    2. No

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

    1. Yes
    2. No

55. THE COVID-19 IMPACT

57. 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/ )

    1. Yes
    2. No
59. Was the business open during the Shelter in Place order?*

    1. Yes
    2. No

61. What is the estimated cost to the business to adhere to recommended safety measures guidelines?*

63. What was the Business’ Monthly Gross Revenue After March 31, 2020?*

65. What Monthly Non-Payroll Expenses is the Business Unable to Pay Due to the COVID-19 crisis?*

67. Please Describe How COVID-19 Has Impacted the Business.*

69. USE OF THE SAFE GRANT FUNDS

71. What is the Business’ Projected Monetary Need for safety measures?*

73. Explain How the Business Will Utilize the SAFE Grant.*

75. It is the intent of Mariposa County that this grant be used to follow all recommended safety measures and guidelines for the business sector. Please specify all purchases necessary to adhere to the recommended guidelines.*

77. SUPPORTING DOCUMENTATION

79. Please provide documentation which supports the business’ expenses. At a minimum, the following documents must be included:*

    • 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.

81. File 2

83. File 3

85. File 4

87. File 6

89. File 7

91. CERTIFICATIONS AND SIGNATURE
    Note: All of the following statements must be checked in order to be considered for the SAFE Grant

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

93. 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*

    1. Yes

95. 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.*

    1. Yes

97. 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.*

    1. Yes

99. 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.*

    1. Yes

101. 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.*

     1. Yes

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

     1. Yes

105. 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.

     1. I Agree
107. APPLICANT CONFIRMATION: I/We understand that any intentional or negligent representation(s) of the information contained on this form may result in civil liability and/or criminal liability and that any fraudulent claims made on this form may be grounds for prosecution under local, state, and federal law. I/We certify under penalty of perjury under the laws of the State of California that the foregoing is true and correct.

Leave This Blank:


109. 1. Receive an email copy of this form.
110. Email address

     This field is not part of the form submission.

111. Submit

* indicates a required field