Covid-19 Economic Impact Survey

Accurate responses to the questions below will assist in evaluating and clarifying the supporting documentation the state is required to submit to the U.S. Small Business Administration when requesting an Economic Injury Disaster Loan Declaration. For your convenience, this form may be filled our electronically or manually.

  • Owner Details

  • Business Owner Mailing Address

  • Business Street Address

  • Estimated Adverse Economic Impact

  • Physical Damage to Business Property

  • If your business also suffered property damage, please answer the following questions:

  • Estimated dollar loss to:

  • MM slash DD slash YYYY