MCNW Oregon IDA Application Form

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FOR OFFICE USE ONLY

MCNW Oregon IDA Application Form

Please fill out this application completely to the best of your ability. Refer to the checklist, on the last 2 pages, for required documents to be submitted with your IDA application. Incomplete applications will not be considered. If you need assistance with filling out this form, please contact the IDA team at (email): [email protected]

Please note: For the fastest response, apply online: https://nw.mercycorps.org/what-we-do/business/portland/grants

Today’s Date: _____________

Applicant’s Legal Name:

Residence Address:

City: County: State: Zip code:

Home Phone #: Mobile/Alternate Phone #:

E-Mail Address: Date of Birth:

Educational Requirement: In the last 12 months, have you completed either Business Foundations I,

Business Foundations II (Rebuilding Your Foundations), a Business Plan Workshop, or a Master Your Credit seminar at Mercy Corps Northwest? If not, have you completed approximately 18 hours of business education at another institution (and do you have a certificate of completion/transcript or letter from your instructor)?

 Yes

 No

If you replied ‘Yes’, list the following information about the class you completed:

Name of Class:

Date class was completed:

Class Provider/Organization:

NOTE: If you replied ‘No’, please do not continue with this application, as you are not eligible to apply for the program at this time.

Are you (or a family member), an employee, or volunteer at Mercy Corps NW?

 Yes

 No

Have you applied to the MCNW IDA Program before?

 Yes

Date received:

Program Staff:

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 No

If ‘Yes’, when? _________________

Are you currently enrolled in an IDA program (at Mercy Corps Northwest or another organization)?

 Yes

 No

NOTE: By law, an individual can only hold one IDA at a time. If you are currently participating in another IDA program, we will not be able to consider your application.

Have you or any member of your household ever participated in an IDA program before?

 Yes

 No

If ‘Yes’, please provide the following information about your past participation:

Name of the Organization:

Date completed the program:

Use or goal of the IDA program:

Match amount received: $

PERSONAL INFORMATION

At Mercy Corps Northwest, we encourage individuals of all backgrounds to apply for our programs, but particularly welcome people from traditionally underserved/undercapitalized populations: those who identify as women, minorities, those transitioning from (or currently experiencing) incarceration, and the homeless/housing insecure.

Gender

 Female

 Male

 Non-binary / Genderqueer

 Trans man/transmasculine

 Trans woman/transfeminine

 Different identity (please state):

 Prefer not to say

Do you identify as LGBTQ+?

 Yes

 No

Do you identify as Hispanic?

 Yes

 No

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Ethnicity/Race (check all that apply):

 American Indian or Alaska Native

 Asian

 Black/African American

 Latina/Latino/Latinx

 Native Hawaiian or Pacific Islander

 White

 Multiracial

 Other (describe in the question below)

Do you identify as another race or ethnicity? Please specify:

What is your Country of Origin (in which country were you born)?

What is your preferred language?

 English

 Spanish

 Arabic

 Other (please specify):

What is your marital status?

 Single, never married

 Married

 Separated

 Divorced

 Widowed

What is your household/family type?

 Single person

 Two or more adults

 Single parent – 1 child

 Single parent – 2 or more children

 Two parent household – 1 child

 Two parent household – 2 or more children What is your housing situation?

Please choose the option that best describes your household's living situation. NOTE: If you are a youth living with family members, choose ‘Youth Living with Family Members’ regardless of whether your family rents or owns a home. Couch surfing, camping, and living in emergency shelters constitute homelessness.

 Rent

 Own

 Youth living with family members

 Sharing housing with friends/family/another household (due to loss of housing or economic hardship)

 Homeless or housing insecure

 Group Home

 Affordable Housing

 Section 8

 Other (Please specify):

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Are you a Veteran?

Veteran can refer to any applicant who identifies as a veteran from any country.

 Yes

 No

What is your highest level of education completed?

 Grades K-5

 Grades 6-8

 Grades 9-11

 High school diploma/GED

 Some college

 Vocational School Diploma/Degree

 AA degree/graduated two-year college

 BA/BS Degree/Graduated four-year college

 Some graduate school

 Graduate degree

Did you complete your education outside the United States?

 Yes

 No

If ‘Yes’, please specify where:

Do you identify as having a disability?

 Yes

 No

Were you in foster care between ages 15-21?

 Yes

 No

Have you ever been incarcerated?

All individuals are eligible to apply, regardless of their level of involvement with the justice system.

 Yes

 No

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HOUSEHOLD INFORMATION

List all household members* below. “Child” is defined as being under 18 years old. If you need to attach additional names, just attach them on a separate document to submit with this application.

Name Adult Child DOB Relationship Monthly Income**

1 Yourself (first name ______________________ ) X Self $

2 $

3 $

4 $

5 $

6 $

7

8

Total: Total: $

* Household definition: all individuals who share a dwelling unit as their primary living and eating space.

Any individual who can be identified as part of the following must be included as part of your household for IDA eligibility purposes:

1. Any individual sharing a unit (home, apartment, other living space) with you.

2. Anyone who considers the unit their primary dwelling place.

3. Anyone who stays at this location for the majority of their time.

Roommates who split expenses and eat separately from each other do not count as part of the household.

**Income definition: any money you (or anyone in your household over 18 yo) bring into your household, including: Alimony, Armed Forces Income, Cash (w/o paycheck), Child Support, Dividend Income, Farm Income, Housing Allowance (i.e. Clergy), Per Capitas, Rental Income, Retirement Distributions, Royalties, Small Business and Self-Employment Income, SSDI (Social Security Disability Insurance) and Veteran's Affairs Disability payments, SSI (Supplemental Security Income), Taxable interest, Traditional Wages, Trust Income, Unemployment, Union Strike Benefits, Worker's Comp.

Your Current Employment Status (check one):

 Employed more than full-time (41+ hours per week)

 Employed full-time (35-40 hours per week)

 Part-time or seasonal

 Unemployed

 Other:

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Your Current Employer (for self-employment, see next section):

Company Name: Employed (month/year) from: to:

City: State: Wage: $ per hour or month (circle one)

Position/Type of Work: Average number of hours worked weekly:

Do you have a business?

 Yes

 No

If ‘yes’, did you file business taxes last year (Schedule C)?

 Yes

 No

Self Employment / Your Business (if applicable):

Business Name:

Started (first sales) Month: Year:

Registered with the State? Yes No

Approx. gross sales of the business last calendar year: $ _ Approx. total income after expenses (profits) last year: $

Type of business: Full-time (35+/week) Part-time or Seasonal Other

Prefer not to say Website or other web presence (Website / Instagram /

Facebook etc): _______________________________

Business email:____________________________________

Business phone number:____________________________

Business address (if different from home):

PUBLIC ASSISTANCE

Have you been certified to receive any of the following public benefits in the past 12 months?

LIEAP (Low Income Energy Assistance Program) Yes No Public Housing Yes No Section 8 Yes No SNAP (food stamps) Yes No TANF (Temporary Assistance for Needy Families) Yes No WIC (Nutrition Program for Women, Infants, and Children) Yes No Low Income Tax Credit properties Yes No

NOTE: If you replied ‘Yes’ to receiving any of the above assistance, you must submit a copy of your official certification letter with your application (i.e. SNAP approval letter, verification from case manager, etc.)

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Calculating the Monthly Gross Income of Your Household

Write down the monthly income received from each source. Try to be as accurate as possible.

Household Income per Month

YOU OTHERS IN THE HOUSEHOLD

YOUR monthly gross salary or wages $ Others’ monthly gross salary or wages $

Self-employment Income $ Self-employment Income $

Investment income $ Investment income $

Child Support/alimony $ Child Support/alimony $

General Assistance (i.e. food stamps, SNAP, TANF)

$ General Assistance (i.e. food stamps, SNAP, TANF)

$

SSI or SSD (Social Security Benefits) $ SSI or SSD (Social Security Benefits) $ Unemployment Compensation (UI, COVID

or PUA)

$ Unemployment Compensation (UI, COVID or PUA)

$

Retirement income (Pension/Annuities/IRAs) $ Retirement income (Pension/Annuities/IRAs) $

Dependent benefits $ Dependent benefits $

Other income

(specify: ___) $ Other income

(specify: ________________ ) $ Other income

(specify: ) $ Other income

(specify: ) $

A. Your Total Income $ B. Other’s Total Income $

TOTAL INCOME (A. Your Total + B. Others Total Income ) $

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Calculating Household Net Worth

Complete the chart below showing what your household owns (assets) and what your household owes (liabilities).

List items that are worth $1,000 or more such as high value equipment, inventory etc. Exclude up to $60,000 of Retirement (Example: if you have $75k in the retirement account, please put $15k as your answer. If you have $50k in the account, put "0")

ASSETS (things you own) Assets (+)

LIABILITIES (things you owe) Liabilities

(-) Vehicle 1

Year:

Make:

Model:

Mileage:

Value: $

Vehicle 2 Year:

Make:

Model:

Mileage:

Value: $ Total Vehicle

Value $

Vehicle 1 Total debt still

outstanding as of today:

$

Vehicle 2 Total debt still

outstanding as of today:

$

Total Vehicle

Debt

$ Home 1

$

Home 2

$

Total Home Value

$

Mortgage 1

$

Mortgage 2

$

Total Home Debt

$

Cash $ Unpaid income/property taxes $

Checking Accounts $ Unpaid child support $

Certificate of Deposits (CDs) $

Credit Cards (MasterCard, VISA, AMEX) $

Savings Accounts $ Store Credit $

Children’s Saving/CDs $ Personal line of credit $

Business bank account balance $ Medical Debts $

Business Asset/Inventory Amount $ Personal Debts (family, friends) $

Retirement (401k/IRA/etc.) $ Student Loans $

Non-retirement Stocks/Bonds $ Business Debts $

Other assets $ Other liabilities $

Subtotal $ Subtotal $

Minus Vehicle 1 $ Minus Vehicle 1 $

Minus Home 1 $ Minus Home 1 $

Total Assets

$ Total

Liabilities

$

Net Worth

(Total Assets minus Total Liabilities) = $

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Do you have a savings account?

 Yes

 No

Do you have a checking account?

 Yes

 No

Have you ever been registered on the ChexSystems®?

 Yes

 No

SHORT BUSINESS PLAN

At what stage is your business?

 Conceptual (I have an idea, did some research)

 Startup (in business less than one year)

 In business for one year or more

Please complete this section below in detail with complete sentences. Feel free to attach additional sheets to better explain your business, business idea, or your personal statement.

1. Briefly describe your business. What products or services will you sell? If you are just starting out, what sort of research/planning have you already done?

2. What is your experience with this product or service?

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3. Do you have previous business experience? What amount of mentorship do you feel you need to achieve your business goals?

4. What other resources have you contacted or used for help with your business?

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5. Personal statement: Please tell us, briefly, about yourself. Why is participation in the Mercy Corps Northwest IDA program important to you? What challenges have you faced as an entrepreneur (financial, personal, educational) that you think will be aided by participation?

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PROPOSED USE OF IDA FUNDS

The Mercy Corps NW IDA Program operates on a 5:1 match ratio. This means that for every dollar you save, you will be matched with $5 in grant money. The savings goal for all participants is $1,000, matched with

$5,000 in grant money, for a total of $6,000. The length of time you save and participate in the program is determined by both your budget (how much you can afford to save) as well as how much time you need to be ready to launch your business plans. All participants must save in the program for a minimum of 6 months.

Please check the plan below that seems best for you (required):

 6 months (Save $167 per month)

What do you plan to do with your IDA account?

 Start a business

 Expand my current business

After you meet the program requirements of 1) reaching your savings goal, 2) attending the required educational hours, 3) writing your business plan, 4) registering your business with the state, 5) obtaining an EIN number for your business, and 6) opening a business bank account, you will receive your grant money! Please describe below how you anticipate using your $6,000 to either start or grow your business. (We understand that this may change over time and we will work with you to finalize your purchase list before you receive your grant).

Proposed Use of IDA Funds (required)

List of Items to Purchase with Grant Money Cost

TOTAL

How did you first hear about the MCNW Asset Builder IDA program?

 Friend

 IDA program participant

 Mercy Corps Northwest staff

 Internet/Email/Social Media

 News media

 Flyer/brochure

 Referred by agency (please specify):

 Other (please specify):

Are you currently using any other services at Mercy Corps?

 Yes

 No

If yes, please identify the service(s):

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REQUIRED DOCUMENTS CHECKLIST

Submit copies (no originals) of the following documents with your IDA application. You will follow the

instructions to submit documents under either Option 1 or Option 2 below, depending on if you received public assistance in the last 12 months and can provide a certification letter as proof. Certify that required documents are included by checking the box next to each document.

Option 1: For those who are recipients of public assistance including LIEAP, Public Housing, Section 8, SNAP, TANF, WIC, or Low-Income Tax Credit properties, your application must include:

 Copy of Oregon ID (or utility bill/lease agreement)

 Copy of public assistance certification letter for any public assistance received in the last 12 months (must be on official letterhead, i.e. SNAP approval letter, WIC enrollment letter, etc.)

 Last year’s business tax return / Schedule C *Only if you were in business last year*

 Class certificate of completion or letter from instructor *Only if you completed prerequisite business education at another organization outside MCNW in the last 12 months*

 Optional: An explanation of any special circumstances to be considered

Option 2: For those who are NOT recipients any of forms of public assistance (or those who are unable to provide documentation of public assistance received), your application must include:

 Copy of Oregon ID (or utility bill/lease agreement)

 Detailed Bank Statements for Last 1 Month (August 2021) from each bank account in the household (personal and business).

 Proof of Income Eligibility for Last 2 Months (July & August 2021). Must include one or more of the following forms of proof of earned income for all household members. Check all that apply to your current income situation and attach required documentation:

 All Pay Stubs for this period (show gross income)

 Letter of Employment if you do not receive pay stubs or are working “under the table”. Letter must include the following information: your name, hours worked over the last two months/pay rate, and signature of employer.

 Copy of your Unemployment Letter if you received unemployment income in the last 2 months. A screenshot of your online unemployment benefits account can be used in place of your official

unemployment letter, if it includes all of the following: your name, dates of benefits received, and benefit amount.

 Profit & Loss Statement from last 2 months if you have income from self-employment. A profit &

loss statement should show all of your business expenses, which are then subtracted from your gross sales to show your profit. It doesn’t have to be fancy, but it should allow us to understand how much you are bringing home from your self-employment. A template Profit & Loss statement can be found on the last page of this application.

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 Last year’s business tax return / Schedule C *Only if you were in business last year*

 Class certificate of completion or letter from instructor *Only if you completed prerequisite business education at another organization outside MCNW in the last 12 months*

 Optional: An explanation of any special circumstances to be considered

I certify that the income and net worth information I have provided in this application is current, complete, and correct to the best of my knowledge. I understand that any intentional misrepresentation may result in my becoming ineligible to continue in the program.

(Applicant’s Signature) (Date)

Submission Instructions

Paper applications can be submitted to the Mercy Corps Northwest IDA team in one of the following ways below.

1. Mail the application and all attached documents to the address listed below.

Mailed applications must be postmarked no later than Friday September 24th to be considered.

2. Scan and send the application and all attached documents to the email listed below.

Emailed applications must be submitted via email no later than 7:00 PM Thursday, September 23rd to be considered.

If you need to request accommodations for an alternate submission option, please contact our IDA team via email or phone.

Mail to:

Mercy Corps Northwest Attn: Olivia Rasmussen 43 SW Naito Parkway Portland, OR 97204

Email: [email protected] Phone: (503) 896-5448

(please leave a voicemail with your name, number, and question/reason for calling and a member of our team will return your call)

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Business Profit & Loss Statement

Period (previous 2 months):

Product / Service Income Income

from sales

$

$ Total Gross Income $

Operating expenses

Marketing $

Bank Service charges $

Credit card fees $

Delivery charges $

Taxes and licenses $

Garbage $

Travel $

Utilities $

Rent and lease $

Electric $

Telephone and Internet $

Shipping $

Other: $

Total Expenses $

Net Profit / Loss

(Total Income – Total Expenses)