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SAMPLE <br />St. Louis Park Small Business Emergency Assistance Report Form <br />As a condition for receiving grant funding, all recipients of St. Louis Park Small Business <br />Assistance are required to submit a brief report to the City of St. Louis Park within two months <br />after receiving grant funds, specifying how the entirety of the grant funds were utilized and <br />provide evidence in the form of paid invoices, statements, bill, or similar documentation. <br />Business name: <br />Business street address: <br />City: State: Zip Code: <br />Name and title of person completing form: <br />1. What was the total amount of grant your business received? $ <br />2. Please specify how grant funds were utilized. Include expenses and amounts up to total amount <br />of grant. For example: Payroll — 2 employees, 2 weeks: $3,000, May Rent - $2,000. Please attach <br />or provide copy of statement, invoice, bill, or similar documentation paid with assistance funds. <br />3. Please describe benefits received from the awarded funds. <br />4. Briefly explain any ongoing business impacts from the COVID-19 pandemic: <br />7 <br />