SBG Application

Authorized Rep

*Are you a U.S Citizen?:

Yes
No

*Are you an enrolled citizen of Tlingit and Haida?:

Yes
No

*Is the business at least 50% owned and operated by the tribal citizen applying for this relief grant?:

Yes
No

Please enter information about you below

*Voting Community:

San Francisco
Pelican

*Tribal Enrollment Number:

*Requested Grant Amount:

*Applicant Name:

*Date of Birth:

*Social Security No.:

*Job Title:

*Home Phone:

Cell Phone:

Work Phone:

Mailing Address

*Mailing Address:

*City:

*State:

*Zip:

APPLICANT BUSINESS INFORMATION

*Business TIN, EIN, or SSN:

*Length of Ownership (Years/Months):

*Permit No. if Applicable:

*DBA or Trade Name if Applicable:

*Business Legal Name:

*Name of Primary Contact if Different from Business Owner:

*Business Address:

*City:

*State:

*Zip:

*Business Phone:

Business Fax:

*Business Email Address:

*For-Profit Entity Business Type (check one):

Sole Proprietor
Partnership
LLC
Independent Contractor
Commercial Fishing
Eligible Self-Employed Individual
Other

Purpose of Funds/Data Collection

Certifications

*My business has been adversely economically injured due to the COVID-19 health emergency and requires small business relief under the Small Business Grant program based upon paying for supporting expenses incurred to replenish inventory or other necessary re-opening expenses.

*My business had 50 or fewer full time equivalent employees as of January 1, 2023, is licensed to do business, and was established prior to February 3, 2023

*The grant proceeds will be used only for the payment of eligible expenses as described in the Schedule of Eligible Expenses attached to this application and in compliance with federal law. I understand that if the funds are knowingly used for unauthorized purposes, Tlingit & Haida may pursue recovery of grant amounts and/or civil or criminal charges. I understand I am required to return any unused funds to Tlingit & Haida

*I am not engaged in any activity that is illegal under federal, state, or local law. (Marijuana related businesses are not eligible)

*I acknowledge and understand that Tlingit & Haida will confirm the grant amount using my Schedule of Eligible Expenses and supporting documentation

*I understand, acknowledge, and agree that Tlingit & Haida may request additional information for the purposes of determining eligibility, and that my failure to provide the information requested may result in a denial of the grant

*I acknowledge that all funds must be spent on eligible expenses on or before December 30, 2023. I have read the statements included in this document and I understand them

*I understand this Supplemental Small Business Grant is taxable income.

Schedule of Expenses

Date:

Name of Expense:

Total:

Cash receipts for expenses incurred are not accepted.

Home Office Self Certification

Dedicated Office Space:

Total square footage of home:

Home Address:

Address Line 2:

City:

State:

Zip:

SQFT x $5.00:

Request for Vendor Set Up

*Legal Name (as shown on your tax return):

*Business Name (if different from above):

*Address:

*City:

*State:

*Zip:

*EIN:

*SSN:

*Email Address:

*Phone Number:

*1099 Vendor (Taxable):

Sole Proprietor
Partnership
LLC
Independent Contractor
Commercial Fishing
Eligible Self-Employed Individual
Other

Authorization for Direct Deposit

First Name:

Last Name:

Mailing Address:

Social Security Number:

Phone Number:

Email Address:

Name of Financial Institution:

Financial Institution Phone Number:

Account Type:

Routing Number:

Account Number:

Please attach documents, receipts, lease agreements, contracts for each item you are seeking relief for your application. Please remember to upload your enrollment ID and business license. Click the Add Another File button for each file you wish to upload. Select the document type from the dropdown menu next to the file name for each file.

Once you press the "Submit" button, your application will not be accessible for editing. An SBG employee will contact you if anything further is needed and to answer any questions.

Enrollment ID
Business License
Certificate of LP/LLP
Commercial Fishing Permit
Articles of Incorporation
Certificate of Incorporation
Bank Statement
Credit Card Statement
Invoice
Purchase order
Lease agreement
Mortgage statement
Payroll expense report
Accounts payable
Utility bills
Written expenses
Other

* By entering my name in the box below I certify that all information is correct and accurate to the best of my knowledge

* Signature:

Thank you, your application has been received.

SBG Application

Central Council of the Tlingit & Haida Indian Tribes of Alaska

2023 Supplemental Rescue Small Business Grant Application

Applications will be accepted until December 29, 2023 OR until all funds have been expended.

Authorized Rep

Purpose of Funds/Data Collection

Certifications

Schedule of Expenses

Home Office Self Certification

Request for Vendor Set Up

Authorization for Direct Deposit

Once you press the "Submit" button, your application will not be accessible for editing. An SBG employee will contact you if anything further is needed and to answer any questions.

Resume Application