COVID Additional Restrictions Grant Scheme Form

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Applicant details

Title

First name

Middle name

Last name

Email address

Phone number

Role in business

Business details

Business name

Business address inc postcode

Description of business

Business SIC code (on Companies House record)

Company or Charity registration number

UTR (for sole traders)

Please note: only sole traders providing serviced holiday accommodation are eligible for a grant

VAT registration number (if applicable)

Date business established

Business rates paid?

Yes

Is your business in a business rated premises?

Yes

Business rates number (if applicable)

Council tax number (if not in business rated premises)

Number of employees

I confirm that the business was trading on or since 30 December 2021

YesNoPlease note: Trading is defined as being engaged in carrying out business activity (a trade or profession) or buying and selling goods or services in order to generate turnover.

Business financial information

What is the latest financial year for which you have full year business financial information?

Total annual business income for the latest financial year available (£)

Total annual costs for the latest financial year available (£)

Explain the impact of the omicron variant in December 2021 on your business

Total income that had been expected in December 2021 period prior to the Omicron variant (£)

Total income now expected for December 2021 period due to the Omicron variant (£)

Total fixed costs incurred in November 2021 period (£)

List the individual cost items incurred in November 2021 (£)

Business Bank details

Account name

Account number

Sort code

Bank address inc postcode

Declaration

Is your business dissolved, in liquidation or subject to a striking off order?

YesNo

Was your business an undertaking in difficulty on 31 December 2021?

YesNo

Maximum Subsidy Allowances: Grants to a company can be paid up to £335,000 over a rolling period of three fiscal years in accordance with Article 364(4) of the Trade and Cooperation Agreement (TCA) with the EU which enables an applicant to receive up to a maximum level of subsidy without engaging Chapter 3 of the TCA. Please note: further information on the allowances can be found in paragraphs 83 – 96 Additional Restrictions Grant Guidance for Local Authorities (updated 30 December 2021).

I confirm that the business has not received subsidies which exceed maximum permitted subsidy allowances under the Small Amounts of Financial Assistance Allowance, COVID-19 Business Grant Allowance or COVID-19 Business Grant Special Allowance over the last three fiscal years

Signing and submission

Confirmation

I agree the following

All information provided in this application is true and that a serious misrepresentation in supplying information may have the following consequences for the signatory that made the misrepresentation:

The Council may sue the signatory for damages under the Misrepresentations Act 1967

If fraud, or fraudulent intent, can be proved, the signatory may be prosecuted and convicted of the offence of fraud by the false representation under s.2 of the Fraud Act 2006, which can carry a sentence of up to 10 years or a fine (or both).

The signatory may be excluded from bidding for Council contracts for three years under regulation 57(8)(h)(i) of the Public Contract Regulations 2015.

I understand that any business caught falsifying their records to gain grant money will face prosecution and any funding issued will be subject to claw back.

By accepting the grant I agree that any information provided through this application will be made available as required from the Local Authority by government for monitoring and assurance of this grant scheme.

Signatory

Full name	Position
Business name	Date

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