ALASKA MENTAL HEALTH TRUST AUTHORITY MICRO ENTERPRISE GRANT APPLICATION

Please thoroughly read the Micro Enterprise Fund Policies and Procedures prior to completing this application.
If you are requesting $500 - $1,000:
You are required to submit this application and this supporting documentation:

Proof of Mental Health Trust Authority Beneficiary Status

Documentation of your dollar for dollar match

Match from DVR: Need proof of DVR approval & signed DVR Release of information form.

Quotes and Specification sheets for items awarded funds will purchase

Short Resume
If you are requesting $1,001 - $10,000:
You are required to submit this application the the following supporting documentation :

Proof of Mental Health Trust Authority Beneficiary Status

Documentation of your dollar for dollar match

If a portion of your match is from DVR: proof of DVR approval

Quotes and Specification sheets for items awarded funds will purchase

Business Plan including the following:

description of business,

operating plan,

financial management plan,

feasibility research,

profit and loss (3 yrs),

cash flow (3yrs),

marketing plan.
*see policies and procedures for more detailed information. You are responsible for reading the policies and procedures and ensuring your application is complete.
Contact Information:
Larrisa Cummings UAA Center for Human Development 2702 Gambell St., Suite 103 Anchorage, AK 99503 1-800-243-2199 (Toll Free) 1-907-264-6279 (Anchorage) 1-907-891-7312 (Fax) megrant@alaskachd.org (Email)
Submit your Application and supporting documents via email, fax, US Postal Service, Fed Ex, or UPS. ALL documents and the completed application MUST be received on or before 12 pm (noon) on the day of the deadline.

For questions 7- 18 below summarize the information contained in your business plan if applicable. If you reference your business plan rather than summarizing information below your application will be incomplete and not reviewed by the committee . During your summary you may reference page numbers in your business plan if committee members require additional information.
Use additional page(s) if you need more room. Please include the question number for each question you are adding additional information.
7) What is your business idea? Briefly describe what products or services your business will sell.
8) What is your operating plan? Briefly describe location, hours of operation, equipment and supplies needed, key personnel, total number of employees, inventory and products or services sold etc.

9) What is your financial management plan? Who will be responsible for the business accounting? Briefly describe how you will document the financial progress of your business; manage payables, receivables, taxes etc.
10) Who are your target customers?

0/1400
11) Who are your competitors?

0/1400

12) Explain why you believe your business will succeed and how the requested funds will affect the outcome.

0/2800
13) What marketing strategies do you plan on using to promote your business?

0/1200
14) Do you plan for your business to be your: (select one)

Primary source of Income Supplement your income
15) Are you receiving disability benefits either SSI, SSDI, or both? (select one)

Yes No N/A
If YES , it is highly recommended that you contact an expert to help you develop a plan to manage your Social Security Benefits and report Net Earnings from Self-employment.
Alaska WIPA Project Larrisa Cummings (907) 264-6279 larrisa@alaskachd.org

16) How will you use the funds you are requesting?

Please list each vendor only once with the total amount of the costs for that vendor. You do not need to list each item from the same vendor individually. Include documentation for showing all items.

EXAMPLE:
Item/Service: Office Supplies
Vendor: General Store
Cost + S&H: $47.65
Vendor Contact: 123 Main Street Anchorage, AK 99503, (907) 555-1212
16a) Item/Service 1:
Vendor 1:
Cost + S&H 1:
Vendor Contact 1:
16b) Item/Service 2:
Vendor 2:
Cost + S&H 2:
Vendor Contact 2:
16c) Item/Service 3:
Vendor 3:
Cost + S&H 3:
Vendor Contact 3:
16d) Item/Service 4:
Vendor 4:
Cost + S&H 4:
Vendor Contact 4:
16e) Item/Service 5:
Vendor 5:
Cost + S&H 5:
Vendor Contact 5:
16f) Item/Service 6:
Vendor 6:
Cost + S&H 6:
Vendor Contact 6:
16g) Item/Service 7:
Vendor 7:
Cost + S&H 7:
Vendor Contact 7:
Total Amount Requested:
17) How are you matching the funds requested above?

**Please note the amount here in question 17 must be greater than or equal to the total amount listed above in question 16.

***If DVR/TVR is going to be matching part of your funds, you must also include the approval or promise letter from them.
17a) Match Amt 1:
Provided by 1:
17b) Match Amt 2:
Provided by 2:
17c) Match Amt 3:
Provided by 3:
17d) Match Amt 4:
Provided by 4:
17e) Match Amt 5:
Provided by 5:
17f) Match Amt 6:
Provided by 6:
17g)Match Amt 7:
Provided by 7:
17h)Match Amt 8:
Provided by 8:
17i) Match Amt 9:
Provided by 9:
17j) Match Amt 10:
Provided by 10:
Total Match Amount:

Now, please share with us information about your support team who will help you succeed in your business plan.
18) Please list the members of your business support team and their roles below.
18a) Name 1:
Agency 1:
Role 1:
Name 2:
Agency 2:
Role 2:
Type a question
Type a question

Type option 1 Type option 2 Type option 3 Type option 4
Name 3:
Agency 3:
Role 3:
Name 4:
Agency 4:
Role 4:
Name 5:
Agency 5:
Role 5:
Name 6:
Agency 6:
Role 6:
Any additional information you would like to share with the review committee, please note below.

0/1400

By typing my full name below, I verify the truthfulness and accuracy of all of the information in this application. Your typed name will count as your digital signature.
Name and Date (typed or printed)
Type your full name and the date
Name of Guardian if applicable (typed or printed)
Type your full name and the date

Please include any additional information needed from Questions 8 - 18 below. Remember to include the question number for each questions you are adding additional information.

Name of Applicant:
Amount Requested
ME Grant Checklist for Applicants

Required Documents for ALL Applications:
Amount of previous award:
Add proof of Beneficiary Status (question 1) here:

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Attach DVR Eligibility, Release of Information (ROI), and Individualized Plan for Employment (IPE) (question 4) here:

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Attach a copy of your Business License (question 6) here:

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If business is different than single proprietorship, include/attach legal documents listing names of all business owners/partners (Example: LLC or Partnership).

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Attach Resume of Applicant here:

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For items or services requested in question 16, it is required to provide an estimate/quote:
- Attach/include documentation or specifications from the Vendor for the items/services requested
- Verify dollar amount for items/services match the documentation precisely
- DO NOT ROUND AMOUNTS! (List them accurately ie $8.98 NOT $9.00)
- Vendor Contact information - name, address, phone - local vendors preferred. Make sure vendor will accept a check. Vendors will only be paid by check.
- Verify the total amount requested is accurate
Attach documentation of items or services requested (question 16) here:

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Match items in question 17

*If items are 1 year or less from date of purchase: Receipt or bill of sale is acceptable. If more than 1 year old, it is assessed at current market value, not replacement value unless purchased by DVR, TVR, or other partner agency. Must have documentation to show current market value.
- Provide documentation of value. Receipts - NOT bank or CC statements.
- Verify that dollar amount listed on the application match documentation.
- If DVR is funding, include the signed DVR Release of Information (ROI) and prior approval noted in the signed DVR Individualized Plan for Employment (IPE)
- Verify total amount is accurate and documents are clearly marked (store/vendor, item, date, amount)
Attach documentation of match items requested (question 17) here:

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Additional Documentation Required if Requesting $1,001 -‐ $10,000 you must also include your Business Plan and Financial Spreadsheet with the following information:
- Description of the business, operating plan, feasibility research, marketing plan etc.
- Financial Management plan
  - Start-‐up budget (if a start-‐up company)
  - Profit and Loss (3 year projections)
  - Cash flow – 3 year (at least 1 year monthly, 2 years quarterly)
  - If this is for expanding a business include financials for previous years in operation (maximum last three years P&L and cash)
Larrisa Cummings – Grant Administrator larrisa@alaskachd.org
Attach your Business Plan and Financial Spreadsheet here:

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