CARES Act Relief Funds

Legal Name of Business

Email Address

New Mexico Taxpayer ID Number

Local Business Registration Number

Do you have a current certificate of good standing? Do you have a current certificate of good standing? Yes No

Business Owner Full First and Last Name

CEO or Other Authorized Representative Full First and Last Name

Is your business headquartered in New Mexico? Is your business headquartered in New Mexico? Yes No

County for the Company's Primary Place of Business

ZIP Code for Company's Primary Place of Business

What type of business do you have? What type of business do you have? C-Corp LLC Partnership Sole Proprietorship Nonprofit

Employee Headcount for Full-time (32 hours/week or more) on 3/1/2020

Employee Headcount for Part-time on 3/1/2020

Current Employee Headcount for Full-time (32 hours/week or more)

Current Employee Headcount for Part-time

March 2019 Total Gross Receipts Tax

April 2019 Total Gross Receipts Tax

March 2020 Total Gross Receipts Tax

April 2020 Total Gross Receipts Tax

Was you business included in the New Mexico orders to shut down or severely curtail business operations? Was you business included in the New Mexico orders to shut down or severely curtail business operations? Yes No

Did you shut down or severely curtail your business activities as a result of closure orders? Did you shut down or severely curtail your business activities as a result of closure orders? Yes No

If so, what date did you close or curtail your business?

If you curtailed rather than closed your business, please describe the nature of the curtailment.

Best estimate of what month you did or will reopen

When you reopen, what percent of capacity do you expect to operate at in May 2020? When you reopen, what percent of capacity do you expect to operate at in May 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in June 2020? When you reopen, what percent of capacity do you expect to operate at in June 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in July 2020? When you reopen, what percent of capacity do you expect to operate at in July 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in August 2020? When you reopen, what percent of capacity do you expect to operate at in August 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in September 2020? When you reopen, what percent of capacity do you expect to operate at in September 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in October 2020? When you reopen, what percent of capacity do you expect to operate at in October 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in November 2020? When you reopen, what percent of capacity do you expect to operate at in November 2020? 0-25% 26-50% 51-75% 76-100%

When you reopen, what percent of capacity do you expect to operate at in December 2020? When you reopen, what percent of capacity do you expect to operate at in December 2020? 0-25% 26-50% 51-75% 76-100%

Net taxable income in the most recent complete tax year

What impact do you anticipate the COVID-19 crisis and related effects will have on your revenues for 2020 as a whole? What impact do you anticipate the COVID-19 crisis and related effects will have on your revenues for 2020 as a whole? No effect 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

If you pay withholding, have you delayed or plan on delaying withholding tax? If you pay withholding, have you delayed or plan on delaying withholding tax? Yes No

Years your business has been in continuous operation through 3/1/2020

How many employees and what total payrool di you report to the state for unemployment insurance taxes for the fourth quarter of 2019? (include # of employees and taxes reported)

Have you been approved for an SBA Paycheck Protection Program loan or Economic Injury Disaster Loan? (check all that apply) Have you been approved for an SBA Paycheck Protection Program loan or Economic Injury Disaster Loan? (check all that apply) SBA Paycheck Protection Program Loan Economic Injury Disaster Loan

Is your business owned by a socially disadvantaged group? (check all that apply) Is your business owned by a socially disadvantaged group? (check all that apply) No Woman Veteran Minority Tribal

Please provide a list of items to be purchased for COVID-19 prevention and/or mitigation and the estimated cost for each item. Use the list of items under “What expenses will be covered?” in the instructions above as a guide.

By clicking "submit" on the online application form, I certify that the information provided in this application is true and that the expenses will not be reimbursed through other CARES Act funds. I understand this grant is for expenses incurred between March 1, 2020 and December 30, 2020 as specified above. I understand that knowingly making a false statement to obtain this grant or providing expenditures that do not qualify may result in the applicant refunding all reimbursed expenditures to the Department of Finance & Administration. By clicking "submit" on the online application form, I certify that the information provided in this application is true and that the expenses will not be reimbursed through other CARES Act funds. I understand this grant is for expenses incurred between March 1, 2020 and December 30, 2020 as specified above. I understand that knowingly making a false statement to obtain this grant or providing expenditures that do not qualify may result in the applicant refunding all reimbursed expenditures to the Department of Finance & Administration. Yes