Estimated Disaster Economic Injury Worksheet for Business

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.

Name of Business

Type of Business

Owner Details

Title

First Name

Last Name

Suffix

Work Phone

Home Phone

Property Owner

Business Owner Mailing Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Business Street Address

Address Line 1

Address Line 2

City

Zip/Postal Code

Estimated Adverse Economic Impact

When did the impact start?

Format: M/d/yyyy

What is the estimated end date?

Format: M/d/yyyy

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

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

Amount of business interruption insurance received, if any:

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

How many people did you employ prior to disaster?

How many did you employ after 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:

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:

First Name

Last Name

Estimated Disaster Economic Injury Worksheet for Business

Empowering Local Business, Enriching Community.