Small Business Survey

COVID-19 economic impact survey

This survey is information that the State of Mississippi and the Small Business Administration will need to make a declaration of disaster area from the COVID-19 pandemic. This information will only be used for these purposes and will not be shared with any outside sources, individuals or businesses. This information is critical to opening Lafayette County for the Economic Injury Disaster Loans (EIDL) to small businesses. Please be as factual as possible. This survey will remain active until Lafayette County has received the designation and the applications for EIDL's is available.

1.Is your business located in Lafayette County, Mississippi(Required.)

Yes

2.Name and address of the affected business

Name of business owner

Business name

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

3.Do you consent to being contacted directly by the EDF to verify your information and submit your information to the State of Mississippi and the Small Business Administration for the purposes of having your area declared a disaster area?

Yes

4.Did your business suffer from a direct economic impact due to the COVID-19 pandemic?

Yes

5.If Yes, What Month and year did the impact start?

Date / Time

Date

SuSunday

MoMonday

TuTuesday

WeWednesday

ThThursday

FrFriday

SaSaturday

6.What were your business revenues during that period?

7.What were your business' revenues during the same time period of the prior year?

8.Amount of business interruption insurance received or anticipated, if any?

9.Provide a brief explanation of what adverse economic effects the disaster has had on your business.

10.How many people did you employ prior to the disaster?

11.How many people did you employ after the disaster?

12.Please estimate your dollar loss to real property (if owned)

13.Please enter your dollar loss to contents (machinery and equipment, furniture and fixtures, inventory, leasehold improvements etc.)

14.Insurance recovery or anticipated for property damages. (if any)

Current Progress,

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