Business Intake Form

Business Intake Form
Name of Applicant

PrefixFirst NameMiddle NameLast Name
Applying as
Your EIN or Social Security Number/ITIN
How many independent contractors do you have?
Business Information
Business Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
What county is your business located in?
Additional business address location(s):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
E-mail of Applicant
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Business Assessment and Forecast Plan
Please provide a brief overview of the small business. Include a summary about the business including information about products and/or services, operation hours and days, and the target markets it serves.
Is the business currently operating?
If no, what date did business close?

MonthDayYear
Date
What business service are you interested in exploring?
Do you have an operating agreement and staffing plan?

Insurance and Financial Section
Do you have insurance that will help to cover your short-term loses? If yes, please complete table with the appropriate options.
Have you completed your Business Taxes
Have you completed your Personal Taxes

Insurance and Financial Information Table 1

Rows	Coverage	Deductible Amount $	Claim Submitted	Funds Received	Amount Received $
*Property Insurance
Commercial General Liability Insurance
Directors/Officers Insurance
Errors & Omissions Coverage
Workers Compensation Insurance
Other

*Standard property insurance policies usually include two types of valuable coverage for disruptions like the coronavirus. Business interruption coverage insures against losses resulting when the policyholder’s operations are directly affected; and contingent business interruption coverage insures against the risk of indirect losses, such as when suppliers or customers are affected.

Disaster Relief Budget Worksheet
Calculator

Please provide 2024 Budget for Business

Rows	12/19 or 1/20	COVID-19 ImpactedCash Flow(1 Month)
Business Revenue
Business Expenses
Balance

Cash Flow needed for 6 months (Balance is multiplied x -6)
Sources to cover 6 month cash flow gap.

Expenses Modified or In Process of Modification

Rows	Monthly Budget Projected
Total Rent Deferred
Accounts Payable Extended
Business Debt Payments Deferred
Available Credit in Lines Open
Insurance Benefits Expected
Any Other Deferred Expenses
Business Cash Available
Personal Savings
Other
Total Available
Working Capital GAP/Request

Working Capital Gap/Request is the Cash flow needed for six months take away from all modified expenses.
Calculator

Grant Amount Requested and Documentation
Grant Amount Requesting
How will you use the Grant Funds

Other
Please include receipts and documentation of the costs that the grant will cover. For the documentation please include the following 1. Documentation of transactions over the last 90 days 2. Bank Statements for at least the last three months.

Cancelof