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Instructions
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Complete all information requested on this application to the best of your ability.
If submitting handwritten form, please
download the printed form and use ink and print legibly.
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Business Information
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FEIN #:
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Business Name
(Legal Name):
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Physical Location of Loss
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Address:
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City:
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State:
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Zip:
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Relocated Business Address(if applicable):
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Business Contact Name:
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Business Contact Telephone Number:
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Type of Business:
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Form of Business (i.e. sole proprietorship, partnership, etc):
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Business Owner's Information
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(Please provide the information requested below for any additional business owners
on a separate sheet, if necessary.)
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Business Disaster related Information
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| Is the Business currently open for business? |
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Description of Business loss:
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How many full time equivalent employess did the business employ at the time of the
2008 natural disaster event?
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Has the Business executed a loan related to the 2008 natural disaster?
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What is the name of the financial institution or agency that provided the disaster
loan?
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What was the total disaster loan amount?
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Please provide a cost breakdown of the proposed use of funds?
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Will any of the disaster loan funds be used for the purchase of energy efficient
equipment and installation, including but no limited to furnaces and boilers, appliances,
air conditioners, hot water heaters, windows, insulation that meets the standards
of the Iowa Office of Energy Independence?
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If so, please list each item and purchase amount:
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Did you or do you expect to receive any rebates applicable to the purchase of this
equipment?
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And, if so, what was the actual total dollar amount of rebates received or the estimated
amount expected to be received?
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What is the name of your gas and electric utility providers?
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I/we certify that all representations, warranties or statements contained in this
application are true, accurate, and complete to the best of my/our knowledge and
belief.
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Attach: Copies of executed loan documents
Copies of sales receipt of energy efficiency equipment purchases (if applicable)
Copies of energy efficiency equipment rebates (if applicable)
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An original signature will be required.
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