Form Center

2. This form is for Small Business Emergency Microloan recipients that received both a Round One (City Funded) and Round Two (CARES Act Funded) microloan. To comply with federal CARES Act regulations, you are required to complete this Final Report by no later than 11:59 p.m. on Friday, January 29, 2021.
4. If you are a recipient of a single microloan, please use either the Round One Final Report form or the Round Two Final Report form available at https://dublin.ca.gov/microloan.
6. If you have any questions about the form, or require assistance to complete the form, please contact Economic Development Staff prior to the deadline by calling 925-833-6650 during business hours.
8. First Name*
9. Last Name*
11. Email:*
13. Business Name *
    (include “doing business as” if any)
15. Business Address*
    (Physical Location)
16. City, State, Zip
18. Website
20. Number of employees currently *
    (include part-time and full-time)
22. Expenditure of Loan Funds
    Note: City of Dublin Small Business Emergency Microloan Funds are to be used only for payment of rent, mortgage, payroll or operating expenses, subject to the restrictions as set forth below, and incurred between March 1, 2020 and December 30, 2020 for business located at the address listed above. Additionally, Round Two Loan Funds are subject to the restrictions set forth in the CARES Act and the United States Department of Treasury’s Coronavirus Relief Fund Guidance for State, Territorial, Local, and Tribal Governments, which can be found at https://home.treasury.gov/policy-issues/cares/state-and-local-governments.
24. Round One (City Funds) Loan Amount*
26. Round Two (CARES Act Funds) Loan Amount:*
28. Total Amount Received:*
30. Were all Round One loan funds spent by December 30, 2020? *

    1. Yes
    2. No
31. If no, list amount remaining:
    Amount of Round One unspent funds
33. Were all Round Two loan funds spent by December 30, 2020? *

    1. Yes
    2. No
34. If no, list amount returned to City:
    Unspent Amount
37. Remitted on
    Date
40. Check Number
42. Please specify how loan funds were spent
    Note: total should equal loan amount (less unexpended funds returned to the City). Enter "0" if no loan funds were used for that purpose.
44. Round One Use of Funds
45. Round Two Use of Funds
47. Rent*
    Amount Spent
48. Rent*
    Amount Spent
50. Mortgage*
    Amount Spent
51. Mortgage*
    Amount Spent
53. Payroll*
    Amount Spent
54. Payroll*
    Amount Spent
56. Operating Expenses*
    Amount Spent
57. Operating Expenses*
    Amount Spent
59. Unspent as of 12/30/2020*
    Amount remaining, if any
60. Unspent amount returned to City*
    Amount unspent by 12/30/2020, if any
62. Round One Total*
63. Round Two Total*
65. Terms and Conditions
    By checking each box below, Borrower affirms the following statements are true:
67. Borrow affirms that:*

    1. Business is still in operation (in some capacity) or has a clear plan to re-open once the State of California and Alameda County permits re-opening of businesses in your industry.
    2. Business has not undergone change in ownership or addresssince receiving loan.
    3. Business is in good standing with the City, including to have a current Business License.
    4. Loan funds have been kept separate from all other funds by use of separate accounts.
    5. Upon request by City, Borrower can provide records to demonstrate that the loan funds have been used in accordance with the Promissory Note.
    6. Such records shall be kept for a period of five (5) years after the full amount of the loan has either been forgiven or repaid.
69. Borrower affirms that no loan funds (Round One or Round Two) were used for:*

    1. Any expense that has been or will be covered by insurance
    2. Any expense that has been or will be reimbursed by a governmental assistance program, not limited to the Paycheck Protection Program, the Economic Injury Disaster Loan Program, etc.
71. Borrower affirms that no Round Two loan funds (CARES Act Funds) were used for: *

    1. Property tax payments.
    2. Capital improvement projects except necessary expenditures incurred due to the COVID-19 public health emergency.
    3. Reimbursement to donors for donated items or services.
    4. Workforce bonuses (excluding hazard pay or overtime), severance pay or legal settlements.
    5. Any other restrictions in accordance with the federal Coronavirus Aid, Relief, and Economic Security Act (Public Law 115-136).
73. If any "Terms and Conditions" box is not checked, please explain:
75. Thank You
    Thank you for being part of the Dublin business community. If you have any questions about the Small Business Emergency Microloan Program, please reach out to the Office of Economic Development via email at economic.development@dublin.ca.gov or call 925-833-6650.
Leave This Blank:


76. 1. Receive an email copy of this form.
77. Email address

    This field is not part of the form submission.

78. Submit Submit and Print

* indicates a required field