Small Business Intake Form

Because the services we provide are made available through public funding sources Fitchburg’s CDBG Program, Massachusetts Growth Capital Corporation (MGCC), United States Department of Agriculture (USDA) and Gardner’s CDBG Program we are asked to keep track of the individuals we serve, the jobs we help to create and the jobs we help to retain.

Please complete the Job Creation and Job Retention Form below.

Technical Assistance Waiver

I agree to hold NEWVUE COMMUNITIES and any third-party representatives harmless against any liability, loss, or damage caused by or arising from the use of any and all information or materials furnished by NEWVUE COMMUNITIES or representative in connection with my participation therein. I further agree to update my business status and job created and retained forms on a regular basis.

Signatures(Required)

I agree to the above.

Business Information

Business Name

Phone

Website

Business Address

Street Address

City

State

ZIP Code

Type of Business

Number of employees at time of filling out this form

Are you beginning a business due to unemployment?

Yes

Phase of your business

New

Existing

Owner Information

Please complete this section for each business owner.

Owner

First Name

Last Name

Residential Address:

Street Address

City

State

ZIP Code

Demographics

Gender

Female

Male

Other/Non-Confirming

Race

American Indian or Alaskan Native

Asian

Asian & White

Black/African American

Black/African American & White

Multi-Racial

Native Hawaiian/Other Pacific Islander

White

Ethnicity

Hispanic

Non-Hispanic

Were you born outside the United States?

Yes

Veteran

Yes

I identify as LGBTQ+

Yes

Household Information

Number of people in household:

Household income in last 12 months

add 2nd owner

Add another owner

Owner Two

First Name

Last Name

Residential Address

Street Address

City

State

ZIP Code

Demographics

Gender

Female

Male

Other/Non-Confirming

Race

American Indian or Alaskan Native

Asian

Asian & White

Black/African American

Black/African American & White

Multi-Racial

Native Hawaiian/Other Pacific Islander

White

Ethnicity

Hispanic

Non-Hispanic

Were you born outside the United States?

Yes

Veteran

Yes

I identify as LGBTQ+

Yes

Household Information

Number of people in household:

Household income in last 12 months

add 3rd owner

Add another owner

Owner Three

First Name

Last Name

Residential Address

Street Address

City

State

ZIP Code

Gender

Female

Male

Other/Non-Confirming

Demographics

Race

American Indian or Alaskan Native

Asian

Asian & White

Black/African American

Black/African American & White

Multi-Racial

Native Hawaiian/Other Pacific Islander

White

Ethnicity

Hispanic

Non-Hispanic

Were you born outside the United States?

Yes

Veteran

Yes

I identify as LGBTQ+

Yes

Household Information

Number of people in household:

Household income in last 12 months

If your company has more than three owners, please complete and submit this form and then contact our office to provide additional information

Signature

My company has received assistance through NewVue Communities, funded through Fitchburg’s CDBG Program and/or Massachusetts Growth Capital Corporation (MGCC) and/or the United States Department of Agriculture (USDA) and/or Gardner’s CDBG Program to either start, continue, expand or stabilize business operations and create/retain jobs, including my own. As a condition of receiving these funds, I have completed forms for each job created/retained (see attached forms). But for this assistance, these jobs would not have been created/retained.

I understand that this information will remain confidential and will be used only to meet the record keeping requirements of the U.S. Department of Housing and Urban Development, which is providing the funds to help create/retain the jobs described on the attached.

This letter, letters ancillary to this letter, and related documents entered into in connection with this agreement are signed when a party’s signature is delivered by facsimile, e-mail, or other electronic medium.

These signatures must be treated in all respects as having the same force and effect as original signatures.

Signatures(Required)

I agree to the above.

Date

MM slash DD slash YYYY

Micro-Enterprise Technical Assistance Income Verification

Your company has received assistance through NewVue Communities, funded through Fitchburg’s CDBG Program and/or Massachusetts Growth Capital Corporation (MGCC) and/or United States Department of Agriculture (USDA) to create, continue or expand its business operations and create or retain jobs, including your own. As a condition of receiving these funds, we are asking your cooperation in completing this form, which will verify both the job creation and income benefits and/or the percentage of jobs which are held by persons of low or moderate income. Please be assured that this information will remain confidential and will be used only to meet the record keeping requirements of the funders(s) including the U.S. Department of Housing and Urban Development.

Position

Please fill this section out for all positions created or retained

This Job Was:

Created

Retained

First Name

Last Name

Street Address

City/Town

State

Zip Code

Job Title

Full- or Part-time

Full-time

Part-time

If Part-time, hours

Race

American Indian or Alaskan Native

Asian

Asian & White

Black/African American

Black/African American & White

Multi-Racial

Native Hawaiian/Other Pacific Islander

White

Ethnicity

Hispanic

Non-Hispanic

Female-headed Household

Yes

Household Income

Please CHECK below the number of people in your household, including yourself

1 ($65,300)

2 ($74,650)

3 ($84,000)

4 ($93,300)

5 ($100,800)

6 ($108,250)

7 ($115,700)

8 ($123,200)

Was your total household income during the 12 months before you accepted this job higher or lower than the amount below the number you checked? Please use taxable income from the last line on page 1 of your last tax return

Higher or lower

Higher

Lower

Date

MM slash DD slash YYYY

Add second position

Add another position

Position Two

This Job Was:

Created

Retained

First Name

Last Name

Street Address

City/Town

State

Zip Code

Job Title

Full- or Part-time

Full-time

Part-time

If Part-time, hours

Race

American Indian or Alaskan Native

Asian

Asian & White

Black/African American

Black/African American & White

Multi-Racial

Native Hawaiian/Other Pacific Islander

White

Ethnicity

Hispanic

Non-Hispanic

Female-headed Household

Yes

Household Income

Please CHECK below the number of people in your household, including yourself

1 ($65,300)

2 ($74,650)

3 ($84,000)

4 ($93,300)

5 ($100,800)

6 ($108,250)

7 ($115,700)

8 ($123,200)

Higher or lower

Higher

Lower

Date

MM slash DD slash YYYY

Signature

I hereby certify that the information contained on this form is accurate and complete to the best of my knowledge, under penalty of law and verifiable by federal government representatives. This agreement, agreements ancillary to this agreement, and related documents entered into in connection with this agreement are signed when a party’s signature is delivered by facsimile, e-mail, or other electronic medium. These signatures must be treated in all respects as having the same force and effect as original signatures.

Signatures(Required)

I agree to the above.

Our Programs

Help With a Home

Small Business

Community Organizing

Small Business Intake Form

Technical Assistance Waiver

Business Information

Business Address

Owner Information

Owner

Residential Address:

Demographics

Household Information

Owner Two

Residential Address

Demographics

Household Information

Owner Three

Residential Address

Demographics

Household Information

Signature

Micro-Enterprise Technical Assistance Income Verification

Position

Position Two

Signature