TIME Program Application

Type of Funding Applying For:

Micro Loan

Forgivable Loan Program

Grant

All of the above

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

Person Submitting Application (Full Name):

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

Applicant's Address:

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

Email Address:

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

Phone number:

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

Section I, Business Information:

Business Name:

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

Business Address:

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

Business Website:

Business Phone:

Business Owner #1 Information:

Full Name:

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

Ownership % (1-100):

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?

Yes

Is Owner #1 Female?

Yes

Does Owner #1 reside in Bartholomew County?

Yes

Business Owner #2 Information:

Full Name:

Ownership % (1-100):

Is Owner #2 Black?

Yes

Is Owner #2 Female?

Yes

Does Owner #2 reside in Bartholomew County?

Yes

Additional Business Owners:

If there are more than two (2) business owners, provide their information here:

Business Status:

New (under 12 months)

Existing (12 months or over)

Business Size (revenue):

Under $500,000 in sales last year

$500,000 or more in sales last year

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

10 or less

More than 10

Date Business Was Established:

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

Tax ID Number:

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?

Yes

If no, explain:

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

Yes

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;

Amount of Funding Requested ($):

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

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

How you plan to use the funding:

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

Have you applied for any grants, PPP, or EIDL loans in the last 12 months? If so, please list funding amounts you received:

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

Yes, Likely

Maybe

Not Likely

If Maybe or Not Likely, what concerns do you have? (Explain):

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

Operating Profit

Personal Income

Other (explain below)

(Other Detail):

Section III, Legal and Other Topics:

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

Yes

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

Yes

Are you currently on probation?

Yes

If you answered "yes" to any of the questions in Section III, please explain:

Section IV, Other Supporting Information:

If there is additional supporting information you would like to provide before your application is reviewed, please explain below:

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.

Upload Signed W9:

Select File

Name (Printed):

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

Name (Signed):

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

Signed Date:

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

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