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EXHIBIT A <br />North Olmsted COVID-19 <br />Small Business Relief Grant Application <br />APPLICANT INFORMATION: <br />1. Business Name: <br />2. Owner Name: <br />3. Business Address (no PO Box): <br />4. Phone Number: <br />5. Email Address: <br />6. Type of Business (LLC, sole proprietorship, etc.): <br />7. EIN Number: <br />8. How many years in business in North Olmsted: <br />9. Number of Employees as of the date of this application filing: <br />10. Please provide a brief description of the business or the goods/services sold: <br />11. Annual operating revenue for the calendar year ending December 31, 2019: $ <br />12. Annual operating expenses for the calendar year ending December 31, 2019: $ <br />13. Average monthly payroll expense for the calendar year ending December 31, 2019: $ <br />14. What is your monthly rent or mortgage payment: $ <br />15. Please provide your operating revenue for the year ending December 31, 2020: $ <br />16. Please provide your operating expenses for the year ending, December 31, 2020: $ <br />17. Estimate business revenue losses due to COVID-19 through December 31, 2020: $ <br />18. Estimate business expense increases due to COVID-19 through December 31, 2020: $ <br />19. Number of jobs you plan to retain between now and June 30, 2021: <br />20. Describe how COVID-19 has impacted your business, including an explanation of any lost revenues <br />and increased expenses indicated above. <br />21. Enter the dollar amount requested (not to exceed $2,500.00): $ <br />4 <br />