ERC Data Request Questionnaire
Your Name
*
First Name
Last Name
Employee Title
*
Will you be the point of contact for the ERC data collection?
*
YES
NO
Name of Point of Contact
Email of point of Contact
example@example.com
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Business Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Is the business address above the address the ERC refund checks should be mailed to/the address on file with the IRS?
Yes
No
Legal Business Name
*
Mailing Address
*
Street Address
Street Address Line 2
City
State
Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Entity Type
*
Sole Proprietorship
General Partnership
Limited Partnership
S Corp
C Corp
Limited Liability Company
Non-Profit
Did you receive government grants/funding in 2020 or 2021 that are allocated towards payroll?
Yes
No
EIN / Tax ID #
*
When did you start your business?
Before February 15, 2020
After February 15, 2020
Date of Incorporation
*
-
Month
-
Day
Year
Date
Was this business part of an acquisition or a startup?
Yes
No
Please briefly describe your trade or business
Please select all of the US States that represents at least 10% of your operations. (Revenue and or Payroll)
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
American Samoa
Puerto Rico
Virgin Islands
Does your business operate in the five Boroughs? (Bronx, Brooklyn, Manhattan, Queens, Staten Island)
*
YES
NO
Have you filed for the Employee Retention Credit for any quarters in 2020 or 2021?
*
YES
NO
What quarters have you filed for the Employee Retention Credit?
*
Q2 2020
Q3 2020
Q4 2020
Q1 2021
Q2 2021
Q3 2021
How many total companies does the majority owner of the business own?
*
Is this business part of a larger organizational structure? (Example: Has a Parent Company, Subsidiary Companies or Private Equity Owned.)
*
YES
NO
Is there more than one entity applying (or plan to apply) for ERC?
*
YES
NO
Other Business's Name
Was the business(s) considered an essential business throughout the COVID-19 Pandemic?
*
Yes
No
What is the name of the person that owns more than 50%?
Did the business have a nonessential portion of the business? if so, please describe the nonessential portion:
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Payroll Details
Do you use a third party payroll processor?
*
YES
NO
Please describe how you process your payroll
*
Who is your payroll processor [Company Name]?
*
Is your business part of a PEO? - NO LONGER USED
YES
NO
Was your business part of a PEO for 2020?
*
YES
NO
Was your business part of a PEO for 2021?
*
YES
NO
What is the name of your PEO?
*
Do you pay a portion of your employees health benefits in 2020 or 2021?
*
YES
NO
# of Employees (Critical Information)
Estimate Number of Employees
*
Did you experience a revenue decline in 2020 or 2021?
*
YES
NO
Did you experience a revenue reduction in any quarter of 2020 vs. 2019 of 50% or greater?
*
YES
NO
I AM NOT SURE
Did you experience a revenue reduction in any quarter of 2021 vs. 2019 of 20% or greater?
*
YES
NO
I AM NOT SURE
Did your business have to change how it operates, in any way due to Covid 19?
*
YES
NO
I AM NOT SURE
Please explain how your business was impacted
Did you receive PPP?
*
YES
NO
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PPP Details
How Many Rounds of PPP Did you Receive?
*
1
2
Did you apply for a PPP loan in 2020 for this entity?
*
YES
NO
2020 PPP Loan Details
Did you apply for a PPP loan in 2021 for this entity?
*
YES
NO
2021 PPP Loan Details
For the year 2020, What was your covered period as indicated on your PPP loan forgiveness application form 3508?
For the year 2021, What was your covered period as indicated on your PPP loan forgiveness application form 3508?
Please check the boxes if you have taken/claimed any of the following credits or grants so that we can make a determination whether it impacts your ERC calculation.
Work Opportunity Tax Credit Employee Retention
Disaster Credit (ERDC)
Air Manufacturing Payroll Support Program
Family and Medical Leave Act Credit (FMLA)
Families First Coronavirus Response Act Credit (FFCRA)
Research and Development Credit
Indian Employment Credit
Active Duty Wage Credit
Empowerment Zone Employment Credit
Shuttered Venue Operator Credit
Paid COVID Sick Leave Credit
Have you taken credits on Paid Family Medical Leave or Work Opportunity Tax Credit?
YES
NO
Have you received or awaiting a Shuttered Venue Operators Grant or RestaurantRevitalization Fund Grant?
YES
NO
Are employer-paid contributions made to a Pension Fund or 401(k) plan?
YES
NO
Was an ERC advance taken on a Form 7200?
*
YES
NO
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Billing Details
Billing Corporation
*
Full Corporate Name of the Company You Would Like BLC to Bill
Billing Contact Name
*
First Name
Last Name
Billing Contact Email
*
example@example.com
Billing Contact Phone #
*
Please enter a valid phone number.
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