cheyenne river sioux tribal venturesfund … application fin… · web viewbusiness owner social...

Cheyenne River Sioux Tribal VenturesFUND APPLICATION FORM

1a. Business Information

Applying Business: Click here to enter text.

Address: Click here to enter text.

Choose City, State, ZIP.

EIN: Enter EIN #Business Owner Social Security Number Enter primary SS#

Contact Person: Enter primary contact name.

1 | P a g eRPF Fund Application Final 7.8.12

Office Phone: Enter phone.Alternate Phone: Enter alternate phone.

E-mail Address: Enter email address.

1b. Additional Business Information

Choose the Funding Category for which this application is for:3&3 Business ($5,000 to $50,000)Amount you are requesting from Tribal Ventures: Click to enter.

Please answer the following questions as they apply :1. Have you been in Business for three years? Yes2. Are you Cheyenne River Reservation based? Yes3. Do you target Cheyenne River Reservation Market? Yes4. Do you employ Cheyenne River Reservation residents? Yes5. Have you employed at least 3 employees within last year? Yes Attach documentation6. Do you have a CRST Tribal Business License? Yes Attach certificate7. Do you have a Cheyenne River Chamber of Commerce Member? Yes Attach certificate8. Do you have a State Tax License? Yes Attach certificate9. Is your business in good standing with the CRST Revenue Office? Yes10. Have you attended the Pre-application Training? Yes Date: Click to enter date.


11. Have you completed business development course such asFour Bands CREATE class? (Required for Start-Up Category Only) Yes Attach certificate

Brief description of your Business Industry (examples- manufacturing, tourism, retail, construction, technology)Click here to enter text.

Brief description of the ProjectClick here to enter text.


2. Business Overview Description of business: Describe your current business including purpose, mission, services, history, customers, employees, and impact on reservation economy?)Click here to enter text.

3. Business Capacity & Network Describe your business’ capacity to accomplish this project.Click here to enter text.

Describe any business development training/services and networks the business owners participate in or have completed. Click here to enter text.

ATTACHMENT A: Copy of Chamber of Commerce membership ATTACHMENT B: Documentation of training and certifications.

4. Financial History – Describe and document the following items to demonstrate the financial health and status of the business. Please attach the following to end of this application

a. Describe your employees on the current payroll. Click here to enter text.


ATTACHMENT C: Provide verification via most recent 941 report or payroll payment summary from business accounting program.

b. Additional Financial DocumentationATTACHMENT D: Documentation of a business bank accounts (copy of recent bank statement)

ATTACHMENT E: Documentation of operational history (tax returns)• 3&3 Category: Required to submit last 3 years of operational history.• Emerging Category: Required to submit operational history equal to the number of years in business.• Start-up Category: Required to submit most recent personal tax returns

ATTACHMENT F: Balance sheet (most recent)

ATTACHMENT G: Profit & Loss (Revenue and Expenditures) last 12 months

ATTACHMENT H: Copy of CRST Business License

ATTACHMENT I: Additional Licensures you may have. (eg. State Sales Tax Licensure or other)

5. Business Plan & Details : Describe business plan or attach business plan (detailed business plan should include at a minimum the following areas):

a. Description of the nature of business expansion and/or effort for this proposal


Click here to enter text.

b. Description of the industryClick here to enter text.

c. Description of the assessment of community needClick here to enter text.

d. Description of the market assessment Click here to enter text.

e. Description of financial management and projections.Click here to enter text.

ATTACHMENT J: Cash flow projection (3 years)

6. Project Description and Plan for Implementation a. Detailed description of the total project (with both TV and matching fund investment).

Click here to enter text.


b. Timeframe of project – describe the project timeframe, include benchmarks and anticipated project completion date.Click here to enter text.

c. Time frame of project: ☐One Year ☐Two Years

d. List project deliverables/benchmarks of progress: Utilize the below chart to describe the anticipated deliverables timeline. (Put an X on the months that it will take you to finish that particular part of the Project)

Example: MonthsList Deliverables: J F M A M J J A S O N D Purchase equipment X X Purchase materials X X Renovate building X X X X Grand Opening X

Year One MonthsList Deliverables: J F M A M J J A S O N DClick here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐


Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐

Year Two MonthsList Deliverables: J F M A M J J A S O N DClick here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐Click here to enter text. ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐ ☐


7. Project Budget and Budget Description

a. Total project Cost – complete the chart below to outline total project cost, including RPF and matching funds amounts and anticipated receipt dates.

Receipt DateTV applied for amount: $ Click here to enter text. Click here to enter text.

Matching fund 1 amount: $ Click here to enter text. Click here to enter text.Matching fund 2 amount: $ Click here to enter text. Click here to enter text.Matching fund 3 amount: $ Click here to enter text. Click here to enter text.Matching fund 4 amount: $ Click here to enter text. Click here to enter text.

In-kind amount $ Click here to enter text. Click here to enter text.TOTAL PROJECT

COST $ Click here to enter text.

b. Required Budget: Uses & Sources Form – complete the chart on the provided Microsoft Excel form to detail Budget Uses and Sources as well as provide a narrative describing the budget line items and matching fund sources.


ATTACHMENT K: Budget Uses and Sources Chart and Narrative

c. Project Budget Expenditure Schedule – Describe the schedule of expenditures of all funds. (Example: Disbursement #1 10/31/12 $20,000, Disbursement #2 11/30/12 $20,000, etc.)Click here to enter text.

8. Project's Benefit to Reservation a. Description of project’s impact on the reservation economy and creating opportunities or service for

low-income people.Click here to enter text.

b. Evaluation – describe below evaluation indicators for Tribal Ventures to track progress of project and to measure success.

i. What will indicate success for your business/industry as a result of this project?Click here to enter text.

ii. What will indicate success for your community as a result of this project?Click here to enter text.

iii. What will indicate success for the reservation as a result of this project?Click here to enter text.


c. Sustainability – Describe the plan and budget for sustaining your project beyond the Tribal Ventures funding investment period.Click here to enter text.


9. Conflict of Interest

If an applicant has a family member or other close relationship with a Tribal Ventures board member or staff, that relationship must be disclosed by the applicant and the Tribal Ventures board or staff member. The Tribal Ventures board or staff member will recuse him/herself from deliberations concerning applications involving family members or other close relationships in writing at the time the application is submitted. Please disclose.

Click here to enter name and relationship.


cheyenne river sioux tribal venturesfund … application fin… · web viewbusiness owner social...

Documents