ERTC

Simmons Capital Partners

ERTC Eligibility Application Form
Legal Business Name
Business EIN
Business Start Date

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please enter the total # of W2 Employees your business had in each of the years below.

	# of W2 Employees
2019
2020
2021

- 2020 941s form for Q2, Q3, and Q4 with the quarterly state unemployment tax and wage report
- 2021 941s form for Q1, Q2, and Q3 with the quarterly state unemployment tax and wage report
- Summary Employee Earnings report for March 13th, 2020 – March 31st, 2020
  
  All these forms would be available in the tax returns you've already filed. You can ask you accountant for them if you don't have quick access.
You may submit this application without all the forms so we can begin on everything else you do have. We will however need them within a day or two after to calculate a final eligibility.
941 Form Upload - Please upload the forms requested above.

Cancelof

Gross Revenue - Please enter the Gross Revenue for each business quarter below.

	1st Quarter	2nd Quarter	3rd Quarter	4th Quarter
2019
2020
2021

If you've taken PPP Loans for this business in the past - please list the amount and date below.

	Amount	Coverage Date
PP1 Loan Amount
PP2 Loan Amount

Applicant Information | Full Name

First NameLast Name
Job Title
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Phone Number
Please enter a valid phone number.
How did the pandemic affect your business? Short paragraph summary.
Would you like to be considered for a business loan as well at this time?

YesNo
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