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2. Each applicant must complete and submit this form once an approved project is complete to receive Small Business Capital Grant funds. 

4. Business Information
6. First Name*
7. Last Name*
9. E-mail*
10. Phone Number*
12. Business Name*
14. Business Address*
15. Address 2
17. City*
18. State*
19. Zip*
21. Business Website
22. Doing Business in Lafayette Since *
24. Number of Employees *

    (full-time and part time)

28. Property Owner Information

    (if different than applicant)

30. First Name
31. Last Name
33. E-mail
34. Phone Number
38. Reimbursement Information
40. Check Payable to:*
41. Total Final Project Cost*
43. Item for Reimbursement 1*
44. Summary*
45. Reimbursement Request*
47. Item for Reimbursement 2
48. Summary
49. Reimbursement Request
51. Item for Reimbursement 3
52. Summary
53. Reimbursement Request
55. Item for Reimbursement 4
56. Summary
57. Reimbursement Request
59. Item for Reimbursement 5
60. Summary
61. Reimbursement Request
63. Item for Reimbursement 6
64. Summary
65. Reimbursement Request
67. Item for Reimbursement 7
68. Summary
69. Reimbursement Request
71. Item for Reimbursement 8
72. Summary
73. Reimbursement Request
75. Item for Reimbursement 9
76. Summary
77. Reimbursement Request
79. Item for Reimbursement 10
80. Summary
81. Reimbursement Request
83. Total Reimbursement Request*
87. Required Documentation
89. Photo of completed project*

    To submit additional photos, please email them directly to Alexander.Nelson@lafayetteco.gov. 

91. All applicable receipts, invoices, and other supporting payment documentation.*
93. Proof of certificate of occupancy (if applicable)
95. *

    1. Agree

    I attest that the information stated above is correct and that I have attached the required documentation.

97. Applicant Signature*
98. Date*
    Date
Leave This Blank:


100. 1. Receive an email copy of this form.
101. Email address

     This field is not part of the form submission.

102. Submit

* indicates a required field