State Farm - LISC Small Business Questionnaire and Discovery Thank you for sharing information prior to one of our lenders reaching out. We will use this information to determine how LISC can be of assistance to you. For business owners with multiple businesses, please answer this questionaire for one business only. Please email SmallBusiness@lisc.org for questions and troubleshooting. Eligibility is based on accurate and complete submission of request to include required documents uploaded. This program is not eligible to employees of State Farm or LISC. Please note that this web page may not save your work if you leave the website before completing and submitting the questionnaire. You may also lose your work if your internet is disconnected, or as a result of other potential web browser issues. We recommend respondents save their answers in a separate document as a backup in case their work in progress on this page disappears for any reason. Question Title * 1. Business Owner First Name Last Name Email Address Phone Number Question Title * 2. Business Information Website (If none put N/A) Legal Business Name Business Address City/Town State ZIP/Postal Code Question Title * 3. Legal Structure of Business For Profit/Corporation Non Profit/Non-stock Corporation Limited Liability Company Partnership (Limited or General) Sole Proprietorship Question Title * 4. What is your primary Industry? Childcare Construction Distribution/Logistics/Warehousing Entertainment Farming/Agriculture Health Care Manufacturing Personal Services (barber shop, cleaners, landscaping, etc.) Professional Services Restaurant/Catering Retail Not For Profit Other (please specify) Question Title * 5. Years in business 10 years or more 6-9 years 3-5 years 2 years or less Question Title * 6. What was your organization's gross income in calendar year 2019 (1/1/2019 to 12/31/2019)? Less than $100,000 $100,000 to $299,999 $300,000 to $499,999 $500,000 or more Question Title * 7. Is your business registered and in good standing with the State of Illinois? Yes No Question Title * 8. Does your company have any Certifications (eg, MBE/WBE/VBE/DBE)? Yes No Question Title * 9. Number of employees prior to December 31, 2019 1 or less 2 to 5 employees 6 to 9 employees 10 or more Question Title * 10. Number of employees after April 1, 2020 1 or less 2 to 5 employees 6 to 9 employees 10 or more The next portion of the survey requests socio-economic data and is required for this grant. Please provide information based on how you self-identify. Information provided through this questionnaire process is the responsibility of each applicant. Questionnaire submitted to the portal remain confidential to the general public and any fellow applicants. Applicants will not hold LISC or, its affiliates, members, partners and staff liable for any losses, damages, costs, or expenses, of any kind relating to the use or the adequacy, accuracy, or completeness of any information loaded in the form. Link to LISC's Privacy Policy Question Title * 11. Age 18-24 25-34 35-44 45-54 55-64 65+ Question Title * 12. Race/Ethnicity (Please specify) American Indian/Alaska Native Asian Black/African American White/Caucasian Hispanic/Latino Other Question Title * 13. Gender Male Female Question Title * 14. Veteran Yes No If Yes, are able to provide DD214? Question Title * 15. How did you hear about program? State Farm News/Social Media LISC Other (please specify) Question Title * 16. Do you own or lease your current business location? Own Commercial Property Lease Home Based Question Title * 17. If lease, has your landlord offered any rent concession or extensions? Yes No Question Title * 18. Are you concerned about your ability to pay your bills in April or beyond? Yes No Question Title * 19. Are you still able to sell your product/services? Yes No Question Title * 20. Please describe the direct and indirect ways COVID-19 has impacted your revenue (i.e. overhead and fixed expenses, local shut down requirements, etc.) Question Title * 21. Is your local government mandating that you close or limit your services or hours of operation? Yes No Not Sure Question Title * 22. Is your organization's work considered "essential"? Yes No Question Title * 23. What alternative services are you offering in light of COVID-19? Question Title * 24. Please check all that apply: Home delivery In-store pick-up On-line services Not applicable Other (please specify) Question Title * 25. Have you applied for any of the following aid due to the impact of COVID-19? Local municipal aid State aid Federal aid Other aid (please describe below) None Question Title * 26. Do you have any loans/UCC liens on the business/organization? Yes No Please describe (optional) Question Title * 27. Are you receiving extensions from lenders? Yes No Please describe (optional): Question Title * 28. General comments or any other information you would like to share with us: Please click "Done" below, to confirm your application was received. If you do not advance on the next page after clicking Done, please review the survey above for incomplete entries, which will be denoted by "!" and messages on what to fix. Please email SmallBusiness@lisc.org for questions and troubleshooting. Done