ESTIMATED DISASTER ECONOMIC INJURY WORKSHEET FOR BUSINESSES

Accurate responses to the questions below will assist in the evaluating a request for an economic injury disaster
declaration from the U. S. Small Business Administration.
Name of Type of
Business: Business:

Owner Details Business Owner Mailing Address

Last Name: Address 1:

First Name: Address 2:

Work Phone: City: State: Zip Code:

Home Phone: County:

Same as Above
Email: Physical Business Street Address

Property Owner: Address 1:

Dates of Economic Impact Address 2:

When did the impact start
and what is the estimated end date? City: State: Zip Code:

From: To: County:

Estimated Adverse Economic Impact

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 or anticipated, 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:

* - includes machinery and equipment,
Contents *: furniture and fixtures, inventory, leashold
improvements, etc.

Date Form
Insurance recovery expected or received for property damages: 11/25/09
Completed:

I certify that the information provided above is correct and accurate to my best knowledge.

Form Completed By: Title:

Print Form Revised 06/07