Seed Capital Request Form, Self-Employment Advisors

APPENDIX B-2

SEED CAPITAL FORMs

(as part of Program Participation Forms)

SET Seed Capital Request Form

Participant Information

Participant’s Name: __________________________________________________________________

First Name MI Last Name

SET Provider: _______________________________________________________________________

Seed Capital Request

Funds requested (not to exceed $1,000 in total for duration of program): $ _______________.______

Proposed use of funds (e.g. inventory, equipment, registration fees, etc): __________________________

__________________________________________________________________________________________________________________________________________________________________________

__________________________________________________________________________________________________________________________________________________________________________

Relation of funds to approved business plan: ________________________________________________ ____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Check to be issued in (circle one): Applicant’s name Vendor’s name

Vendor’s name (if applicable): _______________________________________________________

NOTE: Please attach vendor quotes or other form of official estimate for the request being made.

By signing this seed capital request form, I certify that I have accurately described funds that I will need to cover direct costs that are directly related to the business venture that I am trying to develop. I also understand that, if my request is approved: (1) I will need to provide a copy of the purchase receipt or other documentation to demonstrate that the SET seed capital funds provided were used for the approved purpose(s) and (2) if I misuse SET seed capital funds, I will be terminated from the program.

Participant’s Signature: ______________________________________________________________

Date of Seed Capital Request: ­­­­­­­­­­­­­­­­­­­_________ /_________ / _________ (MM/DD/YYYY)

OMB Control No.: xxxx-xxxx, Expiration Date: xx/xx/20xx

Public Burden Statement

The SET Demonstration is being carried out under the legal authority of PL 105-220 (subtitle D [sections 171 and 172]). Completing this document, which seeks to help the U.S. Department of Labor ensure the satisfactory disbursement of seed capital funds for the SET Demonstration, is required to be considered for a seed capital grant. The public reporting burden for this collection of information is estimated to average 20 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

Seed Capital Request Review

To be completed by designated business advisor

Business advisor’s name:

________________________________________________________________

First Name MI Last Name

Participant’s SET Number: _________________________________

Participant Engagement. Please check the box for the statement that most closely describes the participant’s engagement with the SET program. (Check one only)

 Participant is actively engaged and has completed satisfactorily agreed-upon SET services/activities.

 Participant is not actively engaged and/or has not completed satisfactorily agreed-upon SET services/activities.

Business Development Milestones. Please indicate whether the participant has met the following milestones. Please note that both milestones must be met for the applicant to qualify for the seed capital.

 Participant has a comprehensive and satisfactory business plan.

 Participant has registered their business.

Advisor’s Endorsement of Seed Capital Request: (Check one only)

 Request is APPROVED  Request is NOT approved

Please explain why the request is APPROVED or NOT approved: _______________________________

__________________________________________________________________________________________________________________________________________________________________________

_____________________________________________________________________________________

Signature of business advisor: ________________________________________________________

Request Review Date: ­­­­­­­­­­­­­­­­­­­_________ /_________ / _________ (MM/DD/YYYY)

If APPROVED, please submit completed form to the Mathematica site liaison via the secure online system created by Mathematica. .

OMB Control No.: xxxx-xxxx, Expiration Date: xx/xx/20xx

Public Burden Statement

The SET Demonstration is being carried out under the legal authority of PL 105-220 (subtitle D [sections 171 and 172]). Completing this document, which seeks to help the U.S. Department of Labor ensure the satisfactory disbursement of seed capital funds for the SET Demonstration, is required to be determined eligible to obtain or retain the benefit of a seed capital grant. The public reporting burden for this collection of information is estimated to average 10 minutes per response, including the time for reviewing instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate to the Office of Policy Development and Research, U.S. Department of Labor, Room N5641, 200 Constitution Avenue, NW, Washington, DC 20210.

Seed Capital Request Disposition

To be completed by Mathematica site liaison

Please check the conditions that apply for this request (All must be checked for approval):

 Participant is a member of SET program group

 Participant provided adequate documentation of dislocated worker eligibility

 Participant has completed required milestones

 Participant’s previous seed funding from SET ________ + current request ________ ≤ $1,000

Seed capital request disposition

 Participant will NOT receive the requested SET seed capital funds

 Participant WILL receive the requested SET seed capital funds:

• Participant will receive $ ______________ . ______ in SET seed capital

• Date when check was issued: ­­­­­­­­­­­­­­­­­­­_____ /_____ / _________ (MM/DD/YYYY)

• Purchase receipt/documentation received on: _____ /_____ / ________ (MM/DD/YYYY)