Form WD - Regional Relief and Recovery Fund (RRRF)

Regional Relief and Recovery Fund (RRRF)

The Regional Relief and Recovery Fund provides funding to support businesses that do not qualify for other Government of Canada COVID-19 support measures.

Refer to the Applicant Guide and Instructions before beginning your application. The eligibility criteria, review process and instructions for completing the form are outlined in the Guide. If you have any questions, please call 1-888-338-WEST (9378).

Enter the required information in the space provided. An asterisk (*) indicates a required field.

ORGANIZATION INFORMATION

Legal name of the applicant organization

Operating name if different than Legal Name

Email address

Website

Telephone

Enter a 10 digit number in 999-999-9999 format

Facsimile

Enter a 10 digit number in 999-999-9999 format

Mailing address

Mailing address (Including suite, unit, apt #)

Mailing address line 2

City

Mailing Province/Territory

Postal Code

Must be a valid postal code in A9A 9A9 format.

Legal address same as mailing address

Language

Legal address

Legal address (Including suite, unit, apt #)

Legal address line 2

City

Legal Province/Territory

Postal Code

Must be a valid postal code in A9A 9A9 format.

Organization details

Primary operating facility located in?

Does your business operate on federal lands?

NoYes

What date did your business commence operations in Canada?

Organization type (select best fit)

Business structure

How many employees currently work for your organization?

Is the applicant a(n) (select ALL that apply)

Women-owned business

Indigenous-owned business

Tourism business

ORGANIZATION UNIQUE IDENTIFICATION NUMBER

Provide your CRA business number or GST number (first 9 digits only)

I do not have a CRA business number

Provide incorporation information below

Incorporation type

Incorporation number

In the province of

Date of incorporation

Note: The Primary Contact will be contacted for any follow-up to this application. When the form is submitted, an email will be sent to the email address below.

PRIMARY CONTACT

First Name

Last Name

Title

Email address

Confirm email

Telephone

Enter a 10 digit number in 999-999-9999 format

Cell

Enter a 10 digit number in 999-999-9999 format

FUNDING REQUEST

What amount of WD funding is requested?

Amount cannot exceed $1,000,000

GOVERNMENT OF CANADA COVID-19 SUPPORT MEASURES

Recipients of funding from the following federal relief measures may not be eligible for funding under the Regional Relief and Recovery Fund

If your business is eligible for the Canada Emergency Business Account (CEBA) program, you must first apply to CEBA.
If your business does not qualify for the Canada Emergency Business Account and your business is located in an area serviced by a Community Futures Organization you must apply to the Community Futures Emergency Loan Program.
If you do not meet the criteria of either the Canada Emergency Business Account or Community Futures Emergency Loan Program you may be eligible for funding under the Regional Relief and Recovery Fund.

Has your business applied, received or were deemed ineligible for any of the following federal COVID-19 economic support measures?

Canada Emergency Business Account

Community Futures Emergency Loan Program

GOVERNMENT OF CANADA COVID-19 SUPPORT MEASURES

Recipients of funding from other federal relief measures may not be eligible for funding under the Regional Relief and Recovery Fund

Has your business applied, received or were deemed ineligible for any of the following federal COVID-19 economic support measures?

Canada Emergency Business Account

Canada Emergency Wage Subsidy

Canada Emergency Response Benefit

Canada Emergency Commercial Rent Assistance

10% Temporary Wage Subsidy for Employers

BDC: Co-Lending Program, Working Capital Loan, and Oil and Gas Sector Capital Loan

Canadian Seafoods Stabilization Fund

Community Futures Emergency Loan Program

EDC Business Credit Availability Program

Farm Credit Canada Term Loans, Increased Credit Available for Agriculture, fisheries and aquaculture

Futurpreneur Canada

IRAP Innovation Assistance Program

Support for Indigenous Businesses

Service Canada Work-Sharing Program

Other Government of Canada COVID-19 Support Measure

If you have selected “Approved” for any of the above programs input the total amount of funding received

FINANCIAL INFORMATION

Enter the payroll expenses reported between Jan 1, 2019 – Dec 31, 2019

Is your business pre-revenue?

NoYes

Did your business receive angel or venture capital funding in 2019 or 2020?

NoYes

Enter the amount of revenue generated by your business in 2019

Enter the estimated (%) revenue reduction in 2020 directly related to COVID-19 impacts.

Do not include (%) in answer.

Enter the amount of debt owed by your business

Has your business been in arrears for more than 3 months on outstanding debt in the last year?

NoYes

Enter the amount of equity in your business.

List the total operating costs between April 1, 2020 – Sept 30, 2020.

Utilities

Insurance

Debt expense

Professional fees

Rent

Wages and salaries

Property and business taxes

Other costs

Explain, other costs

Total

List the total revenue between April 1, 2020 – Sept 30, 2020.

Operating balance (calculation)

BUSINESS INFORMATION

Provide a description of your organization and its principle business line(s). (max 1000 characters)

EXPECTED IMPACTS

Describe the impact that COVID-19 has had on your business and how WD funding will enable your business to assist the western Canadian economy to:

retain diverse and valuable talent;
maintain sector knowledge and skills;
maintain capital flow;
maintain critical supply chains and increase capacity to weather supply chain disruptions;
protect technologies and processes that improve resilience, productivity, and/or competitiveness; and/or,
protect vital intellectual property.

(maximum 3500 characters)

Estimate the number (#) of jobs maintained as a result of this relief funding.

Note: this should be measured from the project funding start date (April 1, 2020) to one month following the project completion date (April 30, 2021).

BANK ACCOUNT INFORMATION

Branch number (transit)

Five digits

Financial institution number

Three digits

Account number

Up to twelve digits

Name of Account Holder (s)

If Name of Account Holder is not the Legal Name of the organization, please explain

I, as an authorized representative of the above mentioned organization, authorize the Receiver General for Canada to deposit the payment directly into the account above and to receive payment notifications electronically until further notice.

If funding results from this application, I authorize WD to withdraw from the account above as per the repayment terms of the Contribution Agreement and any subsequent amendments. Should a repayment be returned from the bank, I authorize WD to charge a service fee of $25.00.

AUTHORIZED OFFICIAL OF THE APPLICANT ORGANIZATION ACKNOWLEDGEMENTS

The application form must be submitted by a member of your organization with signing power/authority to enter into a legal agreement.

On behalf of the Applicant Organization I declare that:

The organization suffered a financial hardship resulting from COVID-19 pandemic.

The information provided in this application is accurate.

The organization acknowledges its intention to continue to operate its business in western Canada.

The organization has applied and been declined for Canada Emergency Business Account funding or is not eligible for Canada Emergency Business Account funding.

An audit may be conducted by the Government of Canada or any of its agents to ascertain the veracity of this attestation and the eligibility of the applicant under the program.

The organization will provide the Government of Canada or any of its agents with required financial information.

The organization will use any funding received as working capital in the categories outlined in the operating costs section of this application.

On behalf of the Applicant Organization, I hereby acknowledge and agree that:

This application does not constitute a commitment from Western Economic Diversification Canada (WD) for funding.
Any funds received under this program are repayable contributions to the Government of Canada.
Any person who has been lobbying on behalf of the Applicant Organization to obtain a contribution as a result of this is registered pursuant to the Lobbying Act and was registered pursuant to that Act at the time the lobbying occurred.
The information provided by the applicant on this application and in all supporting documentation is collected under the authority of the Western Economic Diversification Act. This information will be treated in accordance with that Act and with the Access to Information Act and the Privacy Act. These laws govern, protect and limit the collection, use and disclosure of personal and confidential information by federal government departments and agencies. Information provided to WD is secured from unauthorized disclosure and use. WD acknowledges an individual’s rights to privacy of their information, and personal information provided on this application is described in the Personal Information Bank entitled “Grants and Contributions (G&Cs) Programs”, number WED-PPU-055.

For further information about WD’s information holdings and your rights under the Access to Information Act and Privacy Act, consult the Government of Canada’s Info Source publication at www.infosource.gc.ca.

I authorize WD, its officials, employees, agents and contractors to make enquiries of such persons, firms, corporations, federal, provincial and municipal government departments/ agencies, and non-profit, economic development or other organizations as may be appropriate, and to collect and share information with them, as WD deems necessary in order to assess this application, to administer and monitor the implementation of the subject project and to evaluate the results of the project and related Programs.

I have read and agree with the above acknowledgements and certify that all statements and information furnished in this application are true, complete, and correct to the best of my knowledge.

Authorizing Official contact information

First name

Last name

Title

Email address

Confirm email

Telephone

Enter a 10 digit number in 999-999-9999 format

Cell

Enter a 10 digit number in 999-999-9999 format

You must attach a blank "VOID" cheque from the account to be used for electronic payments, OR Obtain a bank letter/confirmation directly from the bank (e.g. Direct Deposit Notification form validated by your bank). If your requested amount of funding is greater than $40,000, you must attach your two most recent year-end financial statements.

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