Estimated Disaster Economic Injury Worksheet for Business

To better help Tri County Economic Development District document the economic impact of COVID-19, area businesses are encouraged to complete and submit this simple form. This form is not required, but it helps to provide clarifying information that supports the documentation the state is required to submit to the U.S. Small Business Administration when requesting an Economic Injury Disaster Loan Declaration.

Thank you for your assistance.

Name of Business * Required
Type of Business * Required
Business Owner's Name * Required
First Last
Business Phone * Required
Home or Mobile Phone
Email
Property Owner * Required
Business Owner Mailing Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Business Street Address * Required
Street Address Address Line 2 City State ZIP Code
Estimated Adverse Economic Impact * Required
When did the impact start?
MM slash DD slash YYYY
What is the estimated end date? * Required
MM slash DD slash YYYY
What were your businesses' revenues during the affected damage period? * Required
What were your businesses' revenue during that SAME period of the prior year? * Required
Amount of businesses interruption insurance received, if any:
Please provide a brief explanation of what adverse economic effects the disaster had on your business: * Required
How many people did you employ prior to disaster? * Required
How many people did you employ after the disaster? * Required
Physical Damage to Business Property
Estimated dollar loss to real property (building) if owned:
Estimated dollar loss to contents*:
*includes machinery and equipment, furniture and fixtures, inventory, leasehold improvements, etc.
Insurance recovery expected or received from property damages?
Form Completed by: * Required
First Last
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