COVID-19 Financial Assistance Request

1. Please enter your name. *

First Name	Last Name

2. What is your company's name?

3. What is your preferred email address to receive our email communications? *

4. What is your work phone number?

5. Please enter your business five digit zip code. *

6. How many full-time jobs (35 hours or more per week) does your business have? Include yourself if you work full-time. *

7. Please select your 2019 total revenue from the choices below. *

	<$10,000
	$10,000 - $99,999
	$100,000 - $1,999,999
	$2,000,000 - $10,000,000
	>$10,000,000

8. What is the NAICS Code that best represents your business? If you are unsure, you can use this keyword lookup tool. *

9. Here is the business start month and year we currently have on file for you. Please make any necessary changes. (enter in MM/YYYY format) *

10. How much funding do you need? *

	<$5000
	$5000 - $9,999
	$10,000 - $49,999
	$50,000 - $99,999
	$100,000 or more

11. How will you use the funding? *

	Pay my salary
	Pay salary for my employee(s)
	Pay supplier(s)
	Make debt payment(s)
	Buy supplies
	Buy equipment

In order to receive disaster assistance, you will need to prove that your business was negatively affected by COVID-19. To do that, you will need ALL of the following documentation.

12. Do you have the following documentation? *

	Business tax returns for 2017 and 2018
	Business tax return for 2019
	Revenues by month for 2019 (2019 income/profit and loss statement)
	Revenues for January and February 2020 (2020 month income/profit and loss statement)
	Assets owned by company at end of 2019 (2019 balance sheet)
	Assets owned by company in 2020 (current balance sheet)
	Business debt schedule (details of current debts - SBA form 2202)
	Business narrative (what your business does, how you have adjusted to the current circumstances, how much money you need and how you will use it, how you will pay back a loan, projected business income statement and current business licenses)
	Personal tax returns for 2017, 2018 and 2019
	Personal financial statement (SBA Form 413)
	Personal credit score

If you are unsure about any of the documentation above or do not have all the documentation, we can connect you to a counselor for help.

13. I would like additional assistance. *

	Please connect me to a counselor
	I am interested in other ways (beyond loans) to manage my finances

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