Address:
If your business also suffered property damage, please answer the following questions:
Estimated dollar loss to:
ESTIMATED DISASTER ECONOMIC INJURY WORKSHEET FOR BUSINESSES
Last Name:
First Name:
Work Phone:
Email:
Business Owner Mailing Address
Business Street Address
From: To:
Owner Details
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:
Real Property (Building), if owned:
Contents *:
Insurance recovery expected or received for property damages:
Property Owner:Home Phone:
City: State: Zip Code:
Form Completed By: Title:
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. For your convenience, this form may be filled our electronically or manually.
When did the impact start and what is the estimated end date?
Estimated Adverse Economic Impact
Physical Damage to Business Property
* - includes machinery and equipment,
furniture and fixtures, inventory, leasehold
improvements, etc.
Revised 05/10
Same As Above
Date Form
Completed:
Name of
Business:
Type of
Business:
County:
Address:
City: State: Zip Code:
County:
