1Page 1 2Page 2 3Page 3 4Page 4 5Page 5 6Summary Progress Page 1 Before you begin Please note: This application process has now closed. Please do not proceed with the form, as you will not be able to submit your application. The Council will use online resources, for example Companies House, Experian and the Insolvency Register, to verify the information provided on the self-declaration form. Information and data will be shared with Government under the National Fraud Initiative (NFI); this matches electronic data within and between public and private sector bodies to prevent and detect fraud. If you provide false or inaccurate information, the Council will take appropriate action. Full details on how we use and store your information are included in the Terms and Conditions and Privacy Notice. Please note that you will need to complete this form in one session. If you close this page, your changes will not be saved. Please make sure that you have read and understood all the support documentation attached. Specifically, please ensure that you have all of the evidence that you are required to upload ready, in the correct format before you begin. View the Guidance Note View the Evidence Checklist View the terms, conditions and privacy notice Please note: The maximum combined file size of all attachments you upload as part of this application must not exceed 18 megabytes. Business details Name of Business/Sole Trader/Self-employed (as registered with Companies house or HMRC) Date business was established Select all that apply It is important that you select all that apply from the following list. Companies House Number Unique Tax Reference Number Registered Charity Number VAT Number This application process has now closed. Please do not proceed with the form, as you will not be able to submit your application. You must choose at least one option to continue. Companies House Number Date of Incorporation Unique Tax Reference Number Registered Charity Number VAT Number Business Address Postcode Find Address Loading addresses... Select Address -- Please select -- Address line 1 Address line 2 (optional) City Postcode Clear postcode/address Use the Lookup Postcode button to find the address.If you cannot find the address, please enter it manually Does your business have commercial premises in other local authority areas? Yes No Please list other locations and addresses in Liverpool City Region (if applicable) Contact details Please provide the contact details of a director of the company/registered charity or the details of partners if the business is not a limited company. Please limit this to two contacts. Partner 1 details (required) Contact name Telephone number Mobile number (optional) Email address Partner 2 details (optional) Contact name (optional) Telephone number (optional) Mobile number (optional) Email address (optional) Number of Employees (a sole director, or self-employed person counts as 1 staff member) Contact email address This email address will be used for any correspondence related to your application. No information is required, please proceed to the next page. Page 2 Operational details Nature of business Business sector -- Please Select -- A: Agriculture, Forestry and Fishing B: Mining and Quarrying C: Manufacturing D: Electricity, Gas, Steam and Air Conditioning Supply E: Water Supply; Sewerage, Waste Management and Remediation Activities F: Construction G: Wholesale and Retail Trade; Repair of Motor Vehicles and Motorcycles H: Transportation and Storage I: Accommodation and Food Service Activities J: Information and Communication K: Financial and Insurance Activities L: Real Estate Activities M: Professional, Scientific and Technical Activities N: Administrative and Support Service Activities O: Public Administration and Defence; Compulsory Social Security P: Education Q: Human Health and Social Work Activities R: Arts, Entertainment and Recreation S: Other Service Activities T: Activities of Households as Employers; Undifferentiated Goods-And Services-Producing Activities of Households for Own Use U: Activities of Extraterritorial Organisations and Bodies Is the business home based? Yes No Upload a Sales invoice for December 2021 (optional) If you are self employed and cannot provide a December 21 sales invoice upload Evidence of cancelled contract/agreement for December 2021 (optional) Upload current business or professional insurance certificate that has not lapsed Do you occupy commercial premises? Yes No Upload full signed lease or mortgage statement or deed Do you pay business rates on the property/properties? Yes No Business rates number(s) Upload business rates bill 2021/2022 (if applicable, even if you receive rate relief) Please confirm the business is viable, trading and continues to trade Yes No Sorry, you are not eligible for this scheme if you are not viable, trading and continue to trade. Bank details Account holder Name of bank Sort code Account number No information is required, please proceed to the next page. Page 3 Evidence All applicants must provide the following additional evidence: Three full months of most recent business bank statements e.g., from 1 October to 31 December 2021. The details must match the name of the business on the business rates bill, lease, utility bill. It must clearly show the name of the bank account holder, business address, sort code, full account number and business transactions. You can upload one bank statement covering three full months or up to three bank statements covering the full three months. A recent utility bill dated within the last 3 months clearly showing your business address (gas, electricity, water, telephone, broadband - please note mobile phone bills are not admissible) Upload most recent full Bank Statements e.g., for 1 October to 31 December 2021 Upload bank statement (month 2) (optional) Upload bank statement (month 3) (optional) Upload recent utility bill dated within the last 3 months showing business address No information is required, please proceed to the next page. Page 4 Business definition Please make your declaration here in relation to being either a Micro or Small business I declare that under the Companies Act 2006, my business is a Micro business I declare that under the Companies Act 2006, my business is a Small business You must confirm at least two of the following requirements and provide the number of employees – include yourself as the sole trader or the self-employed Micro business declaration Turnover: Not more than £632,000 Balance sheet total: Not more than £316,000 No more than 10 employees Small business declaration Turnover: Not more than £10.2 million Balance sheet total: Not more than £5.1 million No more than 50 employees You must confirm at least two of the requirements in order to continue. You must confirm at least two of the requirements in order to continue. Impact of Omicron variant This funding has been allocated to the Liverpool City Region to support businesses in the Hospitality, Leisure and Accommodation sectors, including those in the supply chain that have been seriously impacted by the recent Omicron variant and are not eligible for the Omicron Hospitality and Leisure Grant. You must be able to explain how your business has been seriously impacted by the Omicron variant. Tick below the impact Omicron has had on your business (tick all that apply) and use the text box below to corroborate the impact. Impact Loss of income Loss of turnover Temporary business closure Supply chain issues Cancellations Staff absences Lost contracts Lost bookings Explain the impact the Omicron variant has had on your business No information is required, please proceed to the next page. Page 5 Declaration Please read the below documentation before making your declaration: Guidance note Terms, conditions and privacy notice I confirm that: I confirm that I am not eligible for the Omicron Hospitality and Leisure Grant January 2022 I confirm that, in accepting a grant, the business will remain below the relevant subsidy allowance threshold. Before confirming this please read the guidance note linked above I confirm that all the information provided in this application is accurate and true and that I am authorised to submit this application on behalf of the business outlined in section 1 I confirm that the business is viable, trading and continues to trade I confirm that the business has between 1 and 50 Full Time Equivalent staff (a sole director, or self-employed person counts as 1 staff member) I confirm that this is the only application for the Liverpool City Region Additional Restrictions Grant 3 scheme that has been submitted on behalf of the business named in this application form, and have not submitted another application to the Halton, Knowsley, Sefton, St Helens or Wirral Council(s) I confirm that this business is not in administration, dormant nor insolvent, dissolved or about to be dissolved I also confirm that the business does not have a striking-off notice against it I am not a disqualified Director nor subject to fraud investigations nor have been found guilty of improper business activity or similar I agree that by making this application the business will abide by all of the terms and conditions of the grant set out in the accompanying Terms & Conditions linked above I acknowledge it is a criminal offence to make a misrepresentation that could lead to prosecution I confirm that the business understands that grant income received is taxable and therefore funding paid under the Additional Restrictions Grant 3 will be subject to tax (only businesses that make an overall profit once grant income is included will be subject to tax) I permit the Council to share this information for the prevention and detection of fraud I confirm the business has been seriously impacted by Omicron variant and understand the Council reserves the right to request evidence of loss due to Omicron A claw back arrangement will be made to recover funds that are paid out incorrectly I have read and understood the Council’s privacy notice, linked above You must agree to the above declaration in order to submit your application. If grant applications for ARG3 funding do not meet the anticipated demand, do you wish to be considered for a Top Up grant if funds are available? Yes No Name Position in organisation No information is required, please proceed to the next page. Before you submit this form please review your answers below. If you need to change anything, use the 'previous' button on the bottom left to go back to a section. Then submit the form by selecting the 'Submit button' at the bottom of this page Loading form summary...