ESDC business grant application form, Oct 2001

NYC 9/11 Public Portal Document

Empire3fcii^D evelopment

Charies A. Gargano, Chairman George E. Pataki. Governor

Application for the New York State WTC Disaster Retail Recovery Grant Program The New York State Empire State Development Corporation (“ESDC”) is offering this Grant Program for businesses that are currently engaged in the retail sale of goods or personal services that were located as of September 11, 2001 in the area bordered by the south side of West Houston St. and the south side of East Houston St. from the Hudson to the East Rivers. For each eligible business, the applicant would be entitled to a cash grant up to an estimated 3 days of gross business revenues lost due to business interruption, with a maximum grant of $10,000 per business. Please complete the following items of information. ALL APPLICATIONS MUST BE RECEIVED BY DECEMBER 6,2001. Please mail this Application Form and all required attachments to;

WTC Retail Recovery Grant Program Empire State Development P.O. Box 4438, Grand Central Station New York, NY 10017

Business Name (Legal name of business) Company Name (if different)

Current Address of Business Address as of Sept. 11,2001 (if different)

Contact Person Name Contact Person Telephone Number

Type of Retail / Personal Service Business Number of Employees Tax ID Number

Please attach a photocopy of the following documents as applicable: 1. A photocopy of the 2000 Federal Income Tax Bling: Form 1120 - U. S. Corporate Income Tax Return, OR Form 1065 iR Form 1065-b - Partnership Tax Return, OR Form 1040-Schedule C and Form W2/1099 OR Schedule C-EZ and Form W2/1099

2. A photocopy of the Lease covering the Business Location as of September 11,2001 AND 3. A photocopy of the Current Lease if current location Is different from # 2 above.

Certification of Applicant The undersigned does solemnly affirm that be/she is authorized to execute this instrument, and that to the best of his/her knowledge, information and belief, all statements in this Application, including all attachments thereto, are true and accurate. The undersigned also affirms that it is the Company’s intention to continue operations in New York State or resume a business in New York State that may have temporarily closed due to the events of September 11,2001. The undersigned fijrther affirms that Company is in compliance with all Federal, State and local laws, tax requirements and is not delinquent on any tax obligations. The undersigned understands that receipt of grant funds pursuant to this application is subject to availability of program funds. The undersigned affirms that it is a business in the Eligible Area selling goods or personal services to individual consumers, and that any other business under his/her control has not applied for or received a grant or grants under this program. The undersigned agrees that the name and address of the company and the grant amount may be used by New York State in its promotional materials.

Printed Name Signature

Title Date

ESDC Use: Approved by: Amount Approved S Date:

NYC-WTC_000142128