Cheyenne River Sioux Tribal Venturesfund APPLICATION FORM

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.
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? Yes

2. Are you Cheyenne River Reservation based? Yes

3. Do you target Cheyenne River Reservation Market? Yes

4. Do you employ Cheyenne River Reservation residents? Yes

5. Have you employed at least 3 employees within last year? Yes Attach documentation

6. Do you have a CRST Tribal Business License? Yes Attach certificate

7. Do you have a Cheyenne River Chamber of Commerce Member? Yes Attach certificate

8. Do you have a State Tax License? Yes Attach certificate

9. Is your business in good standing with the CRST Revenue Office? Yes

10. Have you attended the Pre-application Training? Yes Date: Click to enter date.

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

Brief description of your Business Industry (examples- manufacturing, tourism, retail, construction, technology)
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Brief description of the Project
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2. Business Overview

Description of business: Describe your current business including purpose, mission, services, history, customers, employees, and impact on reservation economy?)
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3. Business Capacity & Network

Describe your business’ capacity to accomplish this project.
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Describe any business development training/services and networks the business owners participate in or have completed.

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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.

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

b. Additional Financial Documentation

ATTACHMENT 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

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b. Description of the industry

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c. Description of the assessment of community need

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d. Description of the market assessment

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e. Description of financial management and projections.

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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).
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b. Timeframe of project – describe the project timeframe, include benchmarks and anticipated project completion date.

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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: Months

List 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 Months

List Deliverables: / J / F / M / A / M / J / J / A / S / O / N / D
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Click here to enter text. / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐ / ☐

Year Two Months

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 Date
TV 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.)

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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.

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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?
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ii. What will indicate success for your community as a result of this project?
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iii. What will indicate success for the reservation as a result of this project?
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c. Sustainability – Describe the plan and budget for sustaining your project beyond the Tribal Ventures funding investment period.

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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.

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RPF Fund Application Final 7.8.12