Governor's Request for Disaster Declaration

ESTIMATED DISASTER ECONOMIC INJURY WORKSHEET FOR BUSINESSES

OMB Control Number 3245-0121
Expiration Date XX/XX/XXXX

The Governor of a state or territory is required to submit the information on this form to the U.S. Small Business Administration when requesting an Economic Injury Disaster Loan
Declaration. The information is to be provided by businesses located in the disaster area to support the Governor’s request. Use of this form is not required; the information in any
other format would also be acceptable. For your convenience, this form may be filled out electronically or manually.
PLEASE NOTE: You are not required to respond to this request for information unless it displays a currently valid OMB Control Number. The estimated average burden hours for
responding to this request 2 hours. If you have questions or comments concerning the burden estimate or any other aspect of this request for information, please contact: Director,
Records Management Division, Small Business Administration, 409 Third Street, SW, Washington, D.C. 20416, and SBA Desk Officer, Office of Management and Budget, New
Executive Office Building, Room 10202, Washington, D.C. 20503.

Name of
Business:

Type of
Business:

First Name:

Last Name:
Work Phone:

Email:

Home Phone:

Property Owner:

Address:
City:

State:

Zip Code:

County:
Same as Above

Address:
City:

State:

Zip Code:

County:

From:

When did the impact start and what is the estimated end date?

To:

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:

If your business also suffered property damage, please answer the following questions:
Estimated dollar loss to:

Real Property (Building), if owned:
*includes machinery and equipment,
furniture and fixtures, inventory, leasehold
improvements, etc.

Contents *:
Insurance recovery expected or received for property damages:
Form Completed By:

Title:

Date Form
Completed: