Economic Injury Assistance – Dante Layton | Bookkeeper to Changemakers

Dropdown *

Legal Name *

Federal E.I.N.

Phone *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Business Activity *

Number of Employees (pre-disaster) *

Date Business Established *

Current Management Since: *

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

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

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? *

Has the businessor a listed owner ever had or guaranteed a Federal loan or a Federally guaranteed loan? *

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? *

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? *

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

Was the business in operation one year prior to the disaster? *

Gross Revenues for the twelve (12) month period prior to the disaster: *

Cost of Goods Sold for the twelve (12) month period prior to the disaster: *

Rental properties (residential and commercial) only. Lost rents due to the disaster:

Compensation from other sources received as a result of the disaster (provide a brief description below):