Portland Small Business Relief Fund Application

Eligibility Requirements

Business name*

Does the business serve as the primary source of income for owner?*

YES
NO

Is your principal place of business located in the City of Portland?*

YES
NO

IF NO: Do you have an active City of Portland Business License?*

YES
NO

Was your business in operation and actively registered with the State of Oregon on or prior to December 31, 2019?*

YES
NO
No, it’s not required because I do business under my own name / sole proprietor

Did you have 50 or fewer employees prior to January 1, 2020?*

YES
NO

Have you experienced a decline in revenue since February 1, 2020 due to the COVID-19 public health and economic crisis?*

YES
NO

In 2019, was your annual gross revenue less than $5 million? (Gross revenue means total sales before any money was taken out for taxes or other deductions)*

SI
NO

Details about you and your business

Name (business owner)

First Last

Are there multiple business owners?*

YES
NO

Name(s) of other business owners:

First Last

Name(s) of other business owners:

First Last

Main contact email*

Main contact phone number*

Business address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

DEMOGRAPHIC INFORMATION - Business owner 1

What are your gender identities? (Select all that apply)*

Woman
Man
Non-binary
Two Spirit
Choose not to identify
Prefer to self-describe

please self-describe your gender*

What is your primary racial or ethnic identity?*

please self-describe your primary racial or ethnic identity*

American Indian or Alaska Native

American Indian
Alaska Native
Canadian Inuit, Metis or First Nation
Indigenous Mexican, Central or South American

Tribal Affiliation(s)Enrolled Member:

Tribal Affiliation(s)Descendant:

Asian

Black or African American

Black or African American
African (Black
Caribbean (Black)
Other Black

Middle Eastern / Northern African

Middle Eastern
North African

Hispanic or Latino/a/x

Hispanic or Latino/a/x Mexican
Hispanic or Latino/a/x Central American
Hispanic or Latino/a/x South American
Other Hispanic or Latino/a/x

Native Hawaiian or Pacific Islander

Native Hawaiian
Guamanian or Chamorro
Micronesian
Samoan
Tongan
Other Pacific Islander

White

Eastern European
Western European
Slavic
Other White

ADDITIONAL IDENTITIES (OPTIONAL)

Do you identify as an Immigrant?

YES
NO

Do you identify as a refugee?

YES
NO

Do you identify as LGBTQIA+?

YES
NO

Do you identify as a person with a disability?

YES
NO

Do you identify as a veteran?

YES
NO

DEMOGRAPHIC INFORMATION Business owner 2

What are your gender identities? (Select all that apply)*

Woman
Man
Non-binary
Two Spirit
Choose not to identify
Prefer to self-describe

please self-describe your gender*

What is your primary racial or ethnic identity?*

please self-describe your primary racial or ethnic identity*

American Indian or Alaska Native

American Indian
Alaska Native
Canadian Inuit, Metis or First Nation
Indigenous Mexican, Central or South American

Tribal Affiliation(s)Enrolled Member:

Tribal Affiliation(s)Descendant:

Asian

Black or African American

Black or African American
African (Black
Caribbean (Black)
Other Black

Middle Eastern / Northern African

Middle Eastern
North African

Hispanic or Latino/a/x

Hispanic or Latino/a/x Mexican
Hispanic or Latino/a/x Central American
Hispanic or Latino/a/x South American
Other Hispanic or Latino/a/x

Native Hawaiian or Pacific Islander

Native Hawaiian
Guamanian or Chamorro
Micronesian
Samoan
Tongan
Other Pacific Islander

White

Eastern European
Western European
Slavic
Other White

ADDITIONAL IDENTITIES (OPTIONAL)

Do you identify as an Immigrant?

YES
NO

Do you identify as a refugee?

YES
NO

Do you identify as LGBTQIA+?

YES
NO

Do you identify as a person with a disability?

YES
NO

Do you identify as a veteran?

YES
NO

ABOUT YOUR BUSINESS

Is your business family-owned and operated?*

Yes
NO

Family-owned businesses are majority owned by a member or members of a single family. They are actively involved in the day-to-day management of the businesses and potentially employ fellow family members.

How long have you been in business?*

How many locations does your business have within the City of Portland?*

1
2
3 or more

Is your business a franchise operation?*

Yes
NO

Do you rent or own your space(s)? (If you have multiple locations, select the option for that best applies.)*

Rent
Own

Which of the following best describes your business? (Select one):*

ABOUT YOUR EMPLOYEES

How many employees do you have today? (Include yourself.)*

Which of the following best describes the impact to your workforce during the pandemic*

Added employees
Maintained the same number of employees
Reduced employee hours, but did not lay off employees
Temporarily laid off employees
Permanently laid off employees

How many employees were laid off due to the pandemic?*

IMPACT TO YOUR BUSINESS

Is your business currently open and operating?*

Yes
NO

Are you planning to re-open?*

Yes
NO

How much has your revenue declined due to the public health and economic crisis?*

Given current conditions, how long do you estimate your business can continue operating?*

How has the pandemic affected your business?*

How are you adapting to the new environment? (select all that apply)*

Transition to a mobile workforce
Increasing digital presence (examples: marketing and social media, online sales platform)
Changing business operations
Changing physical space (examples: to-go services, curbside pick-up, expand into the right of way, etc)
Changing business model
I have not made any changes
Other

IF OTHER (Please specify)*

Please select the following programs from which you have received financial support. Select all that apply*

Paycheck Protection Program
Economic Injury Disaster Loan
Other federal assistance
APANO grant
Small Business Relief Fund – grant or loan (Prosper Portland)
Portland Small Business Program for Utility Relief (City of Portland)
I have not received any public funds
Raza Development Fund
Other

IF OTHER (Please specify)*

Have you experienced racial, gender or other biases based on your identity from a lender, financial institution, or landlord in the past?*

YES
NO

How will you primarily use the grant funds?*

Make payroll
Pay late rent or mortgage
Pay other business expenses
Adapt business model or other operational changes
Make physical property improvements to support pandemic public health requirements

Grants will need to be used for expenses incurred between March 1 through December 30, 2020.

Please select the providers with whom you have an existing relationship, if any:

TERMS & CONDITIONS

• I understand that if I am selected for grant funding, Hacienda CDC will share my application and information with Prosper Portland.*

YES

• I understand that Hacienda CDC and the City of Portland may publish details of applicants, including general demographic information, business type, and the ways the grant will support a business. The names of all businesses receiving grants will be published.*

YES

• I understand that this application is subject to public records law and information may be shared with outside sources.*

YES

• I understand and agree that Hacienda CDC and/or Prosper Portland may request further information / documentation if I am selected for a grant award.*

YES

• I certify that (1) all of the information I have provided in this application is true, and (2) neither I nor my business are debarred (legally prohibited) from doing business with the federal government or a state/local government.*

YES

If selected, I understand I could be asked to work with Hacienda CDD and/or Prosper Portland to tell my story and share how this grant helped my business during the pandemic.*

YES

Do you want to sign up for our email list and receive information about additional resources for your business?*

YES
NO