Economic Injury Worksheet

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.

Name of Business*
Type of Business*
What industry are you in?*
Are you still open?*
Have you adjusted your business hours?*
Describe adjustments made to keep your business operational.*
Owner Details
Name*
First Last
Work Phone*
Email*
Home Phone*
Property Owner*
First Last
Business Owner Mailing Address
Address*
Street Address City State ZIP Code
Business Street Address
Address*
Street Address Address Line 2 City State ZIP Code
Estimated Adverse Economic Impact
When did the impact start?*
What is the percentage in loss revenue compared to this time last year? (provide 3 years if applicable)*
Amount of business interruption insurance received or anticipated, if any:*
Please provide a brief explanation of what adverse economic effects the disaster had on your business e.g (inventory and products lost):*
How many people did you employ prior to disaster?*
How many employees have been laid off or furloughed due to this disaster?*
Physical Damage to Business Property
If your business also suffered property damage, please answer the following questions:
Estimated dollar loss to:
Real Property (Building), if owned:
Contents: (includes machinery and equipment, furniture and fixtures, inventory, leasehold improvements, etc.)
Insurance recovery expected or received for property damages:
Date Form Completed*
MM slash DD slash YYYY
Form Completed By*
Title*

Covid-19 Economic Impact Survey

Owner Details

Business Owner Mailing Address

Business Street Address

Estimated Adverse Economic Impact

Physical Damage to Business Property