2. This application is only to be used if you are applying to be placed on the waitlist for the General Assistance grant. Submission of this application does not guarantee funding.

4. Today's Date:*
   Today's Date:
6. Business Name (as shown on your business license):*
8. Business Address:*
10. Business Owner First Name:*
11. Business Owner Last Name:*
13. Business Phone Number: *
14. Cell Phone: *
16. Email Address: *
18. PROGRAM REQUIREMENTS CHECKLIST- City staff will verify accuracy of all answers.
20. Is the business located within the city limits of the City of San Gabriel? *

    1. Yes
    2. No
22. Does your business have an active City of San Gabriel Business License?*

    1. Yes
    2. No
24. Does your business have any unresolved municipal code violations?*

    1. Yes
    2. No
26. Does your business have any unresolved law enforcement violations?*

    1. Yes
    2. No
28. Is the business current on sales tax reporting? *

    1. Yes
    2. No
    3. Not applicable
30. Does your business have 10 or fewer employees, not including the owner? *

    1. Yes
    2. No
32. Has your business previously received the City of San Gabriel's 2021 CDBG Grant or 2022's Small Business Assistance Grant? *

    1. Yes
    2. No
34. Do you have more than one business location?*

    1. Yes
    2. No
36. If YES, please indicate the location you are applying for

    Please note- if you have more than one location, you may only apply for one

38. I, certify that I am the owner (or an authorized agent for the owner)*
    -- Select One --I am the ownerI am an authorized agent for the owner
40. Authorized Agent Name

    If you are not the owner but are an authorized agent for the owner, please provide your first and last name. City staff will contact the business owner to confirm their approval of this application.

42. ACKNOWLEDGEMENT

    I/We HEREBY CERTIFY that the aforementioned facts are true and correct.  I/We understand that acceptance of this Initial Application by the City of San Gabriel does not constitute approval of my/our application. I/We will be liable for all costs incurred through the program if any information provided is determined to be false and/or incorrect which may have initially qualified me/us for the Small Business Assistance Grant Program. The information provided is used strictly for establishing eligibility for the small business assistance grant program.   Applicant(s) acknowledge that personal and financial information may be subject to public disclosure under the California Public Records Act. If chosen for funding, applicant(s) may be required to provide financial documentation and certification of the information provided on the application form, including but not limited to: 2021 Tax Returns, EDD information, and any other applicable documentation.

    Furthermore, if approved, I/We will provide additional documentation and certification of the information provided on the application form prior to grant issuance Note: The information provided on this form is subject to verification at any time.

44. Applicant First Name*
45. Applicant Last Name*
47. Date*
    Date
49. Questions?

    Please contact Caroline Velarde, Economic Development Manager, at 626-457-4674 or cvelarde@sgch.org

Leave This Blank:


51. 1. Receive an email copy of this form.
52. Email address

    This field is not part of the form submission.

53. Submit

* indicates a required field