Disaster Loan Questionnaire

How many employees did you have at the time of the disaster event? *

What state is your business established in? *

What Date did you establish or acquire your business? *

Business Owners – Need Full details of all owners of the business. *

Background and Delinquency

Filed bankruptcy in the past 2 years? *

Yes

Have outstanding judgements, tax liens, or pending lawsuits against them? *

Yes

Currently incarcerated, serving a sentence of imprisonment imposed upon adjudication of guilt? *

Yes

In the past year, been convicted of a criminal offense committed during and in connection with a riot or civil disorder or other declared disaster? *

Yes

Ever been engaged in the production or distribution of a product or service that has been determined obscene by a court of competent jurisdiction? *

Yes

Currently more than 60 days late on paying any child support obligations? *

Yes

Currently suspended or debarred from contracting with the Federal government or receiving Federal grants or loans? *

Yes

Location is in the disaster area (County) *

How did the disaster affect their business? Please be specific. *

Monthly Revenue decreased by _% (compare to prior year) *

Monthly Cost of Good Sold increased/decreased by _% (compare to prior year) *

Monthly Expenses increased/decreased by _% (compare to prior year) *

Special Expenses due to the disaster? *

Did they get reimbursement from the insurance company for disaster loss? *

Have any unresolved federal tax debts? *

Customer Information

First Name *

Last Name *

Email *

Phone *

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