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For each person served through the Community Navigator Pilot Program, one survey must be completed. Enter all data at one time. You will not be able to return to the survey to enter additional information. 

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* 1. I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Community Navigator and host organizations, arising from this assistance.
Purpose of Collection: The information in this form is provided by the Community Navigator grantees and the individuals and businesses seeking assistance from such grantees. SBA is collecting this information for purposes of its oversight and management of the Community Navigator Program authorized under Sec. 5004 of the American Rescue Plan Act of 2021, and to ensure program equity and integrity. Information collected will only be published in summary or aggregate form as a means of providing SBA management officials, Congress, the White House and OMB with reports on program activity and participant outcomes. SBA expects to produce annual reports to the White House, OMB and Congress on the impact of the Community Navigator Pilot Program leveraging aggregate data to illustrate program objectives and outcomes have been met. Please note, SBA may match Form 3516 information with other data sets for program evaluation purposes. In all cases, SBA will protect individual privacy and confidentiality and only aggregate and summary data would be published. Except where indicated otherwise, collection of the information is required to comply with the terms of the Community Navigator award and is important to SBA to help assess how well the program is serving
different communities and to ensure equitable access to the program. Navigators will submit information to SBA according to the terms of their notice of award.

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* 2. I request business counseling service from the Small Business Administration (SBA) or Community Navigator. I agreed to cooperate should I be selected to participate in surveys designated to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services.

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* 3. Client Name (Last, First, MI)

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* 4. Client Email Address

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* 5. Client Telephone

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* 6. Business Street Address

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* 7. Business City

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* 8. Business State

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* 9. Business Zip

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* 10. What is your race?

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* 11. Ethnicity:

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* 12. What is your gender identity?

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* 13. Do you identify as:

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* 14. Military Service

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* 15. Do you consider yourself a person with a disability?

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* 16. Are you currently in business?

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* 17. Date Business Started

Date

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* 18. Legal Name of Business

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* 19. Taxpayer ID

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* 20. Is Taxpayer ID a social security number?

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* 21. Legal Entity

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* 22. Total number of part-time employees

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* 23. Total number of full-time employees

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* 24. Type of Business (check all that apply)

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* 25. For your most recent business year, what was your gross revenue?

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* 26. For your most recent business year, what were your profits?

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* 27. For your most recent business year, what were your losses?

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* 28. Have you applied for or received any SBA services in the past 5 years?

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* 29. If yes, which program(s) (check all that apply)

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* 30. Do you conduct business in a language other than English?

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* 31. Is this a woman-owned business? (51% of the business or stock is owned by one or more women and the management and daily operations are controlled by one or more women)

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* 32. Nature of Assistance Sought

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* 33. What is the dollar amount of loan/grant sought? (Not required)

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* 34. Are you requesting language assistance?

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* 35. Name of Spoke Providing Service

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