Queen Anne's County Nonprofit Assistance Fund

Required Documents:

Completed Application
Most recent 990 Tax Return (if required to file)
FY20 Statement of Financial Position and Statement of Activities (Income Statement /Balance Sheet)
FY21 Year to date Financial Statements.
If seeking assistance with payroll costs please provide the first page of the last 4 quarters of your Maryland Unemployment Quarterly Contribution Report or 941.
Current list of board members.
Organizational Documents including By-Laws.
Additional information can be found on our website www.choosequeenannes.com

Business Name:

Business Address:

Address or Location

Business Federal Employer ID#

First Name of person completing application

Last Name of person completing application

Physical Address

Address or Location

Mailing Address if different than above

Address or Location

Work Phone:

Cell Phone

Website

Email:

Is the nonprofit in compliance with the Maryland Solicitations Act and classified as a tax-exempt organization by the Internal Revenue Service?

******ATTENTION*******

Your business must meet the conditions outlined above to be eligible!

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Is your Business Located In Queen Anne's County?

******ATTENTION*******

Your business must be located in Queen Anne's County to be eligible!

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Briefly describe nonprofit and mission (100 words or less)

NAICS Code (visit www.naics.com to find your code)

Was your organization established before 12/31/20?

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Your organization had to be established before 12/31/2020 in Queen Anne's County to be eligible!

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Years in Business

Is your business in good standing with the State of Maryland?

******ATTENTION*******

Your business must be in good standing with the State of Maryland to apply.

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Is your organization registered with the Office of the Secretary of State Charities Division?

Type of non profit (i.e. 501 (c) (3) or 501 (c) (6) or other)

What date was the organization established?

Did you apply for the Maryland Nonprofit Recovery Initiative (NORI)?

If you were awarded fund please list Amount Awarded

Date Received

Have you applied for the Payroll Protection Program through your Bank?

Where you awarded funds?

Amount Awarded

Date Received

Prior to Covid-19 did the business have any employees?

How many full time employees?

How many part time employees?

Do you currently have employees?

How many full time employees?

How many part time employees?

How many of your current employee's are Queen Anne's County Residents?

Unpaid Taxes: Please list any unpaid Federal,State,Local or Other taxes. Please List the Type,Amount, Amount Past Due and Payment Terms.

Does your business have any outstanding, pending or anticipated claims, liens, judgments or litigation against the applicant?

Please explain any outstanding, pending or anticipated claims, liens, judgments or litigation against the applicant.

Has business defaulted on loan in the last 3 years?

Please provide details of lender, type of loan amount defaulted and status

Has the business ever received a loan or grant from Queen Anne's County?

Please provide information regarding the loan or grant including the Amount,Date and Type.

Has the business ever defaulted on a loan or grant from Queen Anne's County?

Please provide details of the defaulted loan or grant.

It is projected that grant awards will be in the range of $1,000-$10,000. Greater amounts may be awarded to organizations with demonstrated need.

Use of funds can include the following:

Costs related to programming adjustments/expansions necessary to meet the needs of QA citizens and its businesses.
Up to one month of payroll expenses including employer portion of payroll taxes.
Purchases of supplies and equipment.
Up to 3 month’s rent.
Purchase/reimbursement of PPE and other supplies necessary to meet the CDC recommended requirements.
Other mission critical operating expenses.

Please provide a brief overview of request with details on programming, use of funds and amounts requested. If you need more room you can attach a word doc at the end of this application.

If applying for programming and or outreach related needs, please provide the total cost request as detailed above.

If applying for payroll assistance. Please provide your one month payroll expenses including employer portion of payroll taxes.

How many employees will be paid with these funds.

If applying for rent assistance please provide your monthly rent payment for your business location?

Number of months for Rent

Total (up to 3 months) rent requested

Please enter an amount for Equipment and/or supplies. Please provide details, invoices, estimates etc. in attachments at tend of application

If applying for Covid related PPP supplies, please enter an amount for costs related to these items.

Did the business have any other critical operating expenses?

Yes

Please explain other critical operating expenses

Please list the amount of the other critical operating expenses.

Here is the total amount of Covid-19 related operating expenses ( The amount will be calculated automatically)

Please enter your Grant Request Amount

Please provide a brief statement as to how this grant will allow you to serve the citizens of Queen Anne's County.

Please upload your most recent U.S. Tax Return (990)

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Please upload your most recent fiscal year (12 months ending) financial statements either FY20 or FY21

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Please upload your YTD financial statements including income statement and balance sheet.

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Please upload articles of Incorporation/Organization/Formation and by-laws .

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Please upload a current list of board members including titles

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If you have any additional documentation or support please upload here.

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If applying for payroll assistance pleae provide last 4 QTRS of MD Unemployment Quarterly Contribution Reports or 941's

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Please sign here to complete your application.

First Name

Last Name

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All information in this application and in the attached exhibits, attachments, and addendums are true and complete to the best of my/our knowledge, information, and belief