COVID-19 Stimulus Questionnaire

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This field is for validation purposes and should be left unchanged.

ORGANIZATION TYPE

Partnership
Limited Partnership
Corporation
LLC

APPLICANTS LEGAL ENTITY NAME

BUSINESS TRADE NAME (if different than legal name)

FEDERAL E.I.N.

TRADE NAME

(if different from legal name)

BUSINESS PHONE NUMBER

MAILING ADDRESS

Business
Home
Temporary
Other

Address

Street Address Address Line 2 City State ZIP Code

BUSINESS PROPERTY ADDRESS

Street Address Address Line 2 City State ZIP Code

BUSINESS PROPERTY IS

Owned
Leased

CONTACT INFORMATION:

Name*

First Last

Telephone Number*

Email address

BUSINESS ACTIVITY:

GROSS REVENUE FOR 2019:

COST OF GOODS SOLD 2019:

COMPENSATION RECEIVED FROM OTHER SOURCES AS A RESULT OF COVID-19:

Have you received compensation from any other source as a result of Covid-19?

Yes
No

From:

Amount:

Information About Your Organization

BUSINESS ACTIVITY/TYPE

NUMBER OF EMPLOYEES (pre-disaster):

DATE BUSINESS ESTABLISHED:

CURRENT MANAGEMENT SINCE:

OWNERS
Complete for each: 1) proprietor, or 2) limited partner who owns 20% or more interest and each general partner, or 3) stockholder or entity owning 20% or more voting stock.
THIS SECTION MUST BE COMPLETED FOR EACH OWNER

Owner

Name	Title/Office	% Owned	E-mail Address	SSN	Marital Status	Date of Birth	Place of Birth	Telephone Number	US Citizen Yes/No	Address

Click on + icon to add more owners.

If Business Is Owned By An Entity:

Owner Name

First Last

EIN

Type of Business

% Ownership

E-mail Address

Phone

Mailing Address

Street Address Address Line 2 City State ZIP Code

For the applicant business and each owner, please respond to the following questions, providing dates and details on any question answered YES:

a. Has the business or a listed owner ever been involved in a bankruptcy or insolvency proceeding?

Yes
No

Details

b. Does the business or a listed owner have any outstanding judgments, tax liens, or pending lawsuits against them?

Yes
No

Details

c. In the past year, has the business or a listed owner been convicted of a criminal offense committed during and in connection with a riot or civil disorder or other declared disaster, or ever been engaged in the production or distribution of any product or service that has been determined to be obscene by a court of competent jurisdiction?

Yes
No

Details

d. Has the business or a listed owner ever had or guaranteed a Federal loan or a Federally guaranteed loan?

Yes
No

Details

e. Is the business or a listed owner delinquent on any Federal taxes, direct or guaranteed Federal loans (SBA,FHA,VA, student, etc.), Federal contracts, Federal grants, or any child support payments?

Yes
No

Details

f. Does any owner, owner's spouse, or household member work for SBA or serve as a member of SBA's SCORE, ACE, or Advisory Council?

Yes
No

Details

g. Is the applicant or any listed owner currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans?

Yes
No

Details

FOR APPLICANT BUSINESS AND EACH OWNER:

a) are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction
b) have you been arrested in the past six months for any criminal offense
c) for any criminal offense - other than a minor vehicle violation - have you ever: 1) been convicted, 2) plead guilty, 3) plead nolo contendere, 4) been placed on pretrial diversion, or 5) been placed on any form of parole or probation (including probation before judgement)?

FOR APPLICANT BUSINESS AND EACH OWNER

Yes
No

MONTHLY GROSS SALES FIGURES, JANUARY 2017 - FEBRUARY 2020

Monthly Sales Figures

Month	2017	2018	2019	2020

*Please note: the total figures for each year should reconcile to the sales figures on your tax returns for the corresponding fiscal year.

PLEASE SUBMIT ANY ADDITIONAL NARRATIVE OR FINANCIAL INFORMATION YOU FEEL WILL HELP ESTABLISH YOUR ECONOMIC LOSS

It can be helpful to provide a financial forecast to illustrate what the income and expenses for the business will be during the period affected by the disaster until normal operations resume. This is not required. This optional format is provided for your convenience.

Period covered by this forecast.

From	To

Net sales (receipts)

Less cost of goods sold

Gross profit

Less expenses Officers salaries

Employee wages

Advertising

Rent

Utilities

Interest

Taxes

Insurance

Other expenses

Total expenses

Net profit <Loss> before income taxes

SCHEDULE OF LIABILITIES

(Notes, Mortgages and Accounts Payable)

Date of Schedule

Applicant's Name

First Last

SCHEDULE OF LIABILITIES Details

Name of Creditor	Original amount	Original date	Current balance	Current or Delinquent?	Maturity date	Payment amount (Month-Year)	How secured

In the past year, has the business or a listed owner been convicted of a criminal offense committed during and in connection with a rion or civil disorder or other declared disaster, or ever been enganed in the production or distribution of any product or service that has been determined to be obscene by a court of competent jurisdiction?

Yes
No

Is the applicant or any listed owner currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans?

Yes
No

a. Are you presently subject to an indictment, criminal information, arraignment, or other means by which formal criminal charges are brought in any jurisdiction?

b. have you been arrested in the past six months for any criminal offense?

c. For any criminal offense - other than a minor vehicle violation - have you ever been convicted, plead nolo contendere, been placed on pretrial diversion, or been placed on any form of parole or probation (including probation before judgment)?

Yes
No

Signed

Title

Date

Consent*

I agree to terms, click here to read.*