TIME Program Application

Type of Funding Applying For:

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

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

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

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

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

Section I, Business Information:

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

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

Business Owner #1 Information:

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

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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?

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Is Owner #1 Female?

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Does Owner #1 reside in Bartholomew County?

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Business Owner #2 Information:

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

Additional Business Owners:

Business Status:

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Business Size (revenue):

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

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

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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?

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

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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;

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

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

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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?

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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?

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

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Are you currently on probation?

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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

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

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

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

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