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TIME Program Application

Type of Funding Applying For:


This field is required, choose the type of funding you're requesting.


This field is required, include the applicant's full name.


This field is required, include the applicant's address.


This field is required, include the applicant's email address.


This field is required, include the applicant's phone number.

Section I, Business Information:


This field is required, include the name of the business.


This field is required, include the address of the business.

Business Owner #1 Information:


This field is required, include Owner #1's full name.


This field is required, include Owner #1's ownership percentage of the business.
Round to the nearest whole number from 1 to 100.

Is Owner #1 Black?


Is Owner #1 Female?


Does Owner #1 reside in Bartholomew County?


Business Owner #2 Information:

Is Owner #2 Black?
Is Owner #2 Female?
Does Owner #2 reside in Bartholomew County?

Additional Business Owners:

Business Status:


Business Size (revenue):


Number of FULL TIME employees on your payroll at the end of last month:



This field is required, include the date the business was established.


This field is required, include the tax identification number of the business.

Are you currently in good standing with the Secretary of State or equivalent appropriate authority?


Does your business participate in any of the Forms of Operation as listed below?


Forms of Operation:

  • Violates any U.S. federal or state law.

  • Owned/controlled by any government agency, public administration, political organization, or non-profit of any type, including labor groups. 

  • Are engaged in any illegal activity (other than routine traffic violations);

  • Are primarily in the business of manufacturing, promoting or selling diet aids, cannabis, gambling, tobacco (including tobacco-related equipment, such as e-cigarettes), firearms or other weapons. 

  • Are private clubs and businesses which limit the number of memberships for reasons other than capacity or related to applicable U.S. federal or state health guidelines; 

  • Are principally engaged in teaching, instructing, counseling or indoctrinating religion or religious beliefs, whether in a religious or secular setting. 

  • Derive directly or indirectly more than de minimis gross revenue through the sale of products or services, or the presentation of any depictions or displays, of a sexual nature. 

  • Are fraternities, sororities or alumni groups;

  • Are owned by employees, officers and directors of the Columbus Area Chamber of Commerce Foundation, Inc or the NAACP Columbus/Bartholomew Branch 3071 and any affiliated entities, and their respective immediate families (parents, spouse, children, siblings) or individuals residing in their household (whether or not related); 

  • Are listed on the U.S. Department of the Treasury’s Sanctions List.

Section II, Financing Information and Use of Funds:

Funds from this program may only be used for specific expenditures and in certain situations. Please review allowable uses below:

Allowable expenses from Funding

  • Rent, Operating capital for leasing space

  • Cost of Goods Sold (food cost, materials)

  • Marketing materials and advertising including website development and servicing

  • Licenses, dues, subscriptions

  • Phone and Internet

  • Supplies

  • Insurance and/or utilities

  • Staff salaries

  • Equipment Leases and Software Payments, Equipment purchase (with or without installation costs)

  • Purchasing inventory, supplies, accounting and inventory software, furniture, fixtures, and equipment

  • Professional services including legal, financial, business consulting services, 

  • Costs of design and retrofitting businesses to accommodate social distancing, including developing Covid-19 related policies

Ineligible use of Funding

  • Pay off non-business debt, such as personal credit cards for purchases not associated with the business

  • Purchase personal expenses such as buying a new family car or making repairs to a participant's home

  • Purchase personal items, or support other businesses in which the borrower may have an interest

  • Distribute funds to a director or entity owned/controlled by a director

  • Programs designed to influence - or fund through political contributions - a particular law, election or politically-oriented cause, including voter registration and organized labor organizations and programs;

  • Any program that results in direct financial benefit to a specific individual, or an individual sponsorship related to fundraising activities;

  • Religious programs or sectarian programs for religious purposes;


This field is required, include the amount of funding being requested.

Round to the nearest whole number. A dollar sign is not required.


This field is required, include a description of how you plan to use the funding.

If this funding was a loan (interest rate 2%) could you repay it over a four year period of time?


If yes, what is/are your potential source(s) of repayment:

Section III, Legal and Other Topics:

Are you a co-maker, endorser, or guarantor on any loan or contract?


Do you currently have any business bills which are more than 30 days past due?


Are you currently on probation?


Section IV, Other Supporting Information:

Section V, Certifications:

Please read the following and sign the Application Form below.


  • The information in this application is provided for the purpose of applying for funds under the TIME Program.

  • The information is accurate to the best of my knowledge and I understand if I falsify any information it may make me ineligible for future support extended by programs of NAACP Columbus/Bartholomew Branch 3071.

  • I understand that personal and/or business financial and credit information may be requested pursuant to this funding application, and I hereby give my consent for such information to be provided to the NAACP Columbus/Bartholomew Branch 3071, First Financial Bank, and/or Columbus Area Chamber of Commerce, or Columbus Area Chamber of Commerce Foundation representatives.

  • I understand that the TIME program retains the sole discretion as to whether this funding application is approved, disapproved, or modified.

  • I understand that it is my right to accept or decline the funding amount, rate and terms approved through the program.

  • I have included a complete, signed W9 form with this application.

Select File


This field is required, include the printed name of the applicant who signs below.


This field is required, include the digital signature of the applicant.


This field is required, include the date this application was signed.

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