Address:

Project Location

Applicant Information

Basic Project Information

Are you planning or have you completed:

(Not to exceed $15,000)

Demonstrate and certify that the request for funding assistance is associated with COVID- 19 pandemic. Examples could include receipt of loans or other supplemental funding sources from governmental agencies to help support continued employment. Indicate below any sources of funding received or applied for:

X

Project Description: Please provide a written description of your project

Applicants for the Small Business Customer COVID-19 Relief Program Application should provide a clear description/overview of the project. The description should include: project goals, the project budget amount, financial gaps, type of funding needed, an explanation that demonstrate and certify that the request for funding assistance is associated with the COVID-19 pandemic and any other unusual characteristics that will help us evaluate the project.

(Attach additional description if necessary)

Required Supporting Documentation that you must submit with your application. RG&E/NYSEG cannot evaluate any application until all the required information is received.

1. Completed and signed application – (Only needed when above form is not completed)

2. Copy of your W9 form

3. A completed New Vendor Form

4. To demonstrate and certify that the request for funding assistance is associated with the COVID-19 pandemic. Examples could include receipt of payment under the federal government’s Payment Protection Plan, loans, or
other supplemental funding sources from governmental agencies to help support continued employment.

5. Cost estimates and timeline for types of funding you requested at top of page 

6. Letters of support (if available)

7. A copy of your latest RG&E/NYSEG electricity bill or leaseholder of landlord entire —covering the property for which the funding is being requested

8. Business Classification Form