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INTAKE FORM
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FINANCIAL BACKGROUND
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CONTACT US
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INTAKE FORM
FINANCIAL BACKGROUND
CONTACT
Intake Form
Legal Company Name
(required)
Contact Name (Day to day), and information
(required)
Decision Maker Name and information
(required)
Preferred Phone Number
(required)
Preferred Email
(required)
Business Address
(required)
EIN
(required)
Entity Type (C Corp, S Corp, etc)
(required)
Business Effective Date
(required)
Is your business a member of a controlled group or affiliated service group? (If yes, list all companies/businesses that are part of the controlled group)
Do you (or any companies of the controlled group/affiliated service group) sponsor any retirement plan?
Fiscal Year End Date
(required)
State of Incorporation
(required)
Number of Employees
(required)
Payroll Frequency
Open this select menu
Weekly
Bi-Weekly
Semi-Monthly
Monthly
Please provide ownership Structure of the Adopting Employer (name of individual and percentage ownership), and any other commonly-owned business where an owner of the Adopting Employer owns 5% or more of the business
Does the Adopting Employer or any other companies in the Controlled Group own any other companies?
Names of Relatives employed by relatives (if any)
(required)
Did you receive a PPP?
(select all that apply ) [Required]
PPP1
PPP2
None
PPP1: Date Received, Amount Received, Percentage Forgiven
PPP1 Forgiveness: What is the coverage period and quarter forgiven?
(required)
8 Weeks
Quarter 1
Quarter 2
Quarter 3
Quarter 4
24 Weeks
Quarter 1
Quarter 2
Quarter 3
Quarter 4
PPP2: Date Received, Amount Received, Percentage Forgiven
PPP2 Forgiveness: What is the coverage period and quarter forgiven?
(required)
8 Weeks
Quarter 1
Quarter 2
Quarter 3
Quarter 4
24 Weeks
Quarter 1
Quarter 2
Quarter 3
Quarter 4
Select the qualifying event(s) that apply to you
(select all that apply)
Full shutdowns
Partial shutdowns
Interrupted operations
Supply chain interruptions
Inability to access equipment
Limited capacity to operate
Inability to work with your vendors
Reduction in services or goods offered to your customers
Cut down in you hours of operation
Shifting hours to increase sanitation of your facility
Impact to your normal operations
Unable to fly or attend trades shows in person
Gross receipts declined by 50% in 2020 from 2019
Gross receipts declined by 20% in 2021 from 2019
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SUBMIT FORM