Estimated Disaster Economic Injury Worksheet for Businesses

2. This form is not required, but is a convenience in 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. This information in any other format would also be acceptable.

   This form is not required, but is a convenience in 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. This information in any other format would also be acceptable.

4. Name of Business *

5. Type of Business:*

7. Owner Details

9. Last Name*

10. First Name*

12. Work Phone*

13. Email*

15. Home Phone

16. Property Owner*

18. Business Owner Mailing Address

20. Mailing Address*

22. City*

23. State

24. Zip

25. County*

27. Business Address (Location)

29. Business Address*

31. City*

32. State

33. Zip

34. County*

36. Estimated Adverse Economic Impact

38. When did the impact start and what is the estimated end date?
    When did the impact start and what is the estimated end date? Start Date

    —

    When did the impact start and what is the estimated end date? End Date

40. What were your businesses' revenues during the affected damage period?

42. What were your businesses' revenues during that SAME period of the prior year?

44. Amount of business interruption insurance received or anticipated, if any:

46. Please provide a brief explanation of what adverse economic effects the disaster had on your business:*

48. How many people did you employ prior to disaster?*

49. How many people did you employ after disaster?

51. Physical Damage to Business Property
    If your business also suffered property damage, please answer the following questions:

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

53. Estimated dollar loss to Real Property (Building), if owned:

54. Estimated dollar loss to Contents

    Note: Contents includes machinery and equipment, furniture and fixtures, inventory, leasehold improvements, etc.

56. Insurance recovery expected or received for property damages:

58. Date Form Completed*
    Date Form Completed

59. Form Completed By:*

60. Title*

Leave This Blank:


62. 1. Receive an email copy of this form.
63. Email address

    This field is not part of the form submission.

64. Submit Submit and Print

* indicates a required field