ERTC SURVEY Chris G.

ERTC SURVEY
Company - Legal Entity - Name*
Business Owner Name*
Business Owner Email*
example@example.com
Business Owner Cell Phone Number*
Please enter a valid phone number.
Address *
City*
State*
Zip Code*
Contact Person (If different than business owner)
Contact Number (If different than business owner)
Email (If different than business owner)
example@example.com
Consultant Name*
1. What is the average number of employees per quarter? (Q2-Q4 2020)*
b.What is the average number of employees per quarter? (Q1 - Q3 2021)*

2. What is the quarterly wage for W-2 employees (This information can be found in the quarterly wage report)?*

	Number of Employees	Quarterly Payroll Amount
Q2- 2020
Q3- 2020
Q4- 2020

3. What is the quarterly wage for W-2 employees (This information can be found in the quarterly wage report)?*

	Number of Employees	Quarterly Payroll Amount
Q1- 2021
Q2- 2021
Q3- 2021

4. What are the wages paid per quarter to any owner of 50% or greater? NOTE 1. Must be included in the payroll summary. 2) If owners are 50/50, add both wages together below.*

	Wages
Q2- 2020
Q3- 2020
Q4- 2020

5. What are the wages paid per quarter to any owner of 50% or greater? NOTE 1. Must be included in the payroll summary. 2) If owners are 50/50, add both wages together below.*

	Wages
Q1- 2021
Q2- 2021
Q3- 2021

ERTC SURVEY CONT’D
6. Wages earmarked for PPP forgiveness:
a. How much was received for the 1st round of PPP?*
i. What amount went towards wages?*
b. How much was received for the 2nd round of PPP?
ii. What amount went towards wages?
7. Was the business deemed non-essential during full or partial government shutdown?*

YesNo
8. Was the business deemed essential but had trouble sourcing equipment, supplies, etc.,?*

YesNo
9. What cover period was used when applying for forgiveness of the 1st PPP Loan?*

8 weeks24 weeks
a.Start date*

MonthDayYear
Date
b.End date*

MonthDayYear
Date
10. What cover period was used when applying for forgiveness of the 2nd PPP Loan?

8 weeks24 weeks
a.Start date

MonthDayYear
Date
b.End date

MonthDayYear
Date
11. What type of Entity is your business?*

C CorpS CorpPartnershipNon-ProfitLLCSole Proprietor
12. Do you use a PEO?
The Estimate you will be given is a “rough” estimate based on the data provided in the client survey. It does not prove or attempt to prove that an employer qualifies for a recovery.
How to Qualify
Reduction in Gross Receipts: An employer is eligible based on reduction of Gross Receipts 2020: 50% or greater drop in Gross Receipts vs the same quarter in 2019 2021: 20% or greater drop in Gross Receipts vs the same quarter in 2019
Other Considerations
Full shutdowns*

YesNo
Partial shutdowns*

YesNo
Interrupted operations*

YesNo
Supply chain interruptions*

YesNo
Inability to access equipment*

YesNo
Limited capacity to operate*

YesNo
Inability to work with your vendors*

YesNo
Reduction in services or goods offered to your customers*

YesNo
Cut down in your hours of operation*

YesNo
Shifting hours to increase sanitation of your facility*

YesNo
* COVID Impact Statement
If you answered “YES” to any of the questions under “Other Considerations” we may request additional supporting documentation on company letterhead.
Should be Empty:

ERTC SURVEY

ERTC SURVEY CONT’D

How to Qualify

Other Considerations

* COVID Impact Statement