Tell President Barack Obama, your senator and congresspersons how you would stimulate the economy TODAY.
Print this sample application out, complete the information and fax or mail to President Obama and your senators and congresspersons. January 2009
US Economic Stimulus Program APPLICANT QUESTIONNAIRE
Please take a moment to tell us about yourself.
1. How many employees do you have? (Include yourself) ________
2. How many jobs will be created by this economic stimulus loan? ________
2a. Please give the job descriptions and requirements for jobs on a separate on a separate piece of paper.
3. How many jobs will be retained? ________
3a. Please give the job descriptions and requirements for jobs on a separate on a separate piece of paper.
___YES ___NO 4. Will these job positions be filled within the next month?
how many____
___YES ___NO 4a 3 months? how many____
___YES ___NO 4b 6 months? how many____
___YES ___NO 4c 9 months? how many____
___YES ___NO 5. How is this business involved in rebuilding the infrastructure of the country? please describe in detail on a separate piece of paper what part of infrastructure and how this business contributes to the rebuilding of the country- examples- engineering and construction of medical IT, roads, highway, railway, canal, levee, seaport, airport and air traffic control systems, bike path and bridge construction, mass transit public transportation, self sustainability structures, alternative energy, schools and hospitals, emergency services such as police and fire fighting, and basic financial services, water supply management, power grids, generation plants, substations and power distribution systems, telecommunications, landline telephone systems, cell phone network, internet backbone, communications satellites, undersea cables, waste management, drainage systems, irrigation systems, flood control systems, public works, global positioning systems, etc.
5a. include in your description details of how the monies given would be spent.
___YES ___NO 6. Have you ever been charged with or arrested for any criminal offense other than a minor vehicle violation (including offenses which have been dismissed, discharged, or nolle prosequi)?
___YES ___NO 7. Have you ever been convicted, placed on pretrial diversion, or placed on any form of probation including adjudication withheld pending probation for any criminal offense other than a minor vehicle violation?
___YES ___NO 8. Are you presently under indictment, on parole or probation?
___YES ___NO 9. Do you have any judgments on your credit file?
___YES ___NO 10. If you are at least a 50% or more owner of applicant business, are you more than 60 days delinquent on any obligation to pay child support arising under an administrative order, court order, repayment agreement between the holder and a custodial parent, or repayment agreement between the holder and a state agency providing child support enforcement services?
___YES ___NO 11. Do you have defaulted student loans?
___YES ___NO 12. Is your credit or business clear of all tax liens?
___YES ___NO 13. Have you ever filed bankruptcy?
___YES ___NO 13a. If YES, has it been discharged for at least two or more years?
___YES ___NO 14. Is your business a start-up (under 3 years old)?
___YES ___NO 15. Have you lived in your community longer than 8 months?
___YES ___NO 16. Do you have a business checking account in the name of the business applying for the loan?
___YES ___NO 17. Do you plan to use loan proceeds to pay off current judgments or give executives bonuses?
___YES ___NO 18. Are you a U.S. citizen?
___YES ___NO 19. If you are not a U.S. citizen can you provide a copy of your “green card?”
15a. If no, what kind of visa or alien registration receipt do you have? _______________
___YES ___NO 20. Do you have any other Government loans outstanding?
___YES ___NO 21. If your business is a start-up, do you have 3 or more years of prior experience in that type of business?
___YES ___NO 22. Is your business a franchise?
___YES ___NO 23. If you are purchasing a franchise is your franchise an approved SBA franchise?
___YES ___NO 24. Would you describe your credit as being “extremely challenged?”
___YES ___NO 25. Are your total liquid assets (cash on hand) greater than $100,000? (Excluding your home & auto)
___YES ___NO 26. Are you presently debarred, suspended, proposed for debarment, declared ineligible or voluntarily excluded from participation in this transaction by any Federal department or agency?
___YES ___NO 27. Are you a veteran of the United States Armed Forces?
___YES ___NO 27a. If veteran, when and what branch?__________________________
___YES ___NO 28. Does your business export any of its products or services, or do you plan to begin exporting as a result of this loan?
___YES ___NO 28a. If yes, estimated total export sales this loan will support: $________________ _
___YES ___NO 29. Have you, the business, or its affiliates ever requested government financing?
___YES ___NO 29a. If yes, is any of the financing currently delinquent?
___YES ___NO 29b. Did any of this financing ever default and cause a loss to the government?
___YES ___NO 30. Has an application for a loan for this business ever been submitted to SBA under any program?
___YES ___NO 31. Have you, the business, or its affiliates had a previous SBA loan?
___YES ___NO 31a. If yes, is the loan either current or paid in full?
___YES ___NO 32. Does your business accept Medicare or Medicaid for payment?
___YES ___NO 33. Do you have ownership in any other companies?
33a. If yes, what percentage do you own? ________%
Legal Name of Business
Trade Name (dba)
Federal Employer Tax ID (FEIN)
Number of Employees
Present Mgt Since (Date)
Date Business Established
Number of Locations:
Business Phone Number
Business Fax Number
Address City State Zip
Website Address:
Email:
Briefly Describe your business: 25 words or less
Average Annual Sales $
Average Annual Net Profit $
Is the Business a Franchise?
If yes, give name of franchisor:
How much do you need? $________
PERSONAL INFORMATION:
Principal Owner Name:
Title:
Date of Birth:
Home Tel Number:
% of Ownership
Address City State Zip
Rent or Own: How long:
(if less than 2 years, provide previous address):
ID Type: (Driv. License) State of Issuance: ID Number Issue Date Expir. Date
Cash in Bank:
Employment Income:
Spouse Income:
Other Income:
Total Annual Income:
By signing below, I acknowledge that I have answered these questions truthfully and to the best of my knowledge and/or recollection.
__________________________________________________________
Signature of Business Owner
__________________________________________________________
__________________________________________________________
Print Name Date