SBA Form 3516
OMB Control Number 3245-XXX
Expiration Date:
Community Navigators Program Client and Program Information Form
Use of Information Collected: The information in this form is provided by individuals and businesses seeking assistance from a Community Navigator. The information is collected to help SBA’s oversight and management of the Community Navigator Program, ensure program equity and integrity and to meet Congressional and Executive Branch reporting requirements. Only the client, the grantee and SBA will be privy to the individualized confidential and proprietary information. Any personal information collected will be protected to the extent permitted by law, including the Privacy Act of 1974 and the Freedom of Information Act. SBA has instituted procedures to protect confidentiality and only aggregate and summary data will be provided in public reports to the Congress and White House.
Name of Entity Providing the Service
City/State of Office Location
Part I
Client Name (Last, First, MI)
Telephone
Street Address, City, State, Zip
Part II- Business Information
Race (mark one or more): American Indian or Alaska Native, Asian, Black or African America, Native Hawaiian or Other Pacific Islander, White, Other
Ethnicity: Hispanic or Latino, not Hispanic or Latino, Other
Gender: Male, Female, Non-binary, Other
Sexual Orientation: LGBTQ, Not LGBTQ, Other
Do you consider yourself a person with a disability? Yes/no
Military Status: No military service, Service Disabled Veteran, Active Duty, Spouse of Military Member
Are you currently in business? Yes/no (if no, skip to #26)
Name of Business
Taxpayer ID #
Is this a social security number? Yes/no
Type of Business: Mining, Utilities, Information, Construction, retail Trade, Manufacturing, Finance & Insurance, Wholesale, Public Administration, Educational Services, Real Estate & Rental & Leasing, Health Care & Social Assistance, Accommodation & Food Service, Arts, Entertainment & Recreation, Transportation & Warehousing, Professional, Scientific & Technical Services, Management of Companies & Enterprises, Agriculture, Forestry, Fishing & Housing, Administrative & Support, Waste Management & Remediation Services, other services (except Public Administration)
Business Ownership: What percentage of your business is male/female owned? %male, %female
Date Business Started
Legal Entity: Sole Proprietor, Corporation, S-Corporation, LLC, Partnership, Other
Total Number of Employees (full and part time)
For your most recent business year list: Gross Revenues and Profits/losses
Do you conduct business in a language other than English?
Location: Urban, Rural
Are you requesting assistance in English? Yes/no (insert language request)
Nature of Assistance Sought: Paycheck Protection Loan/Forgiveness, Covid Economic Injury Disaster Loan, Restaurant Revitalization Fund, Shuttered Venues Grant, Other SBA Disaster Loans, 7(a) loan, 504 loan, Microloan, Export Loan, Other Loan, State/local grant, Other grant, SBA Contracting Certification, Assistance Starting a Business, Other
What is dollar amount of loan/grant sought?
Have you applied for or received any SBA services in last 5 years?
If yes, which program(s) (check all that apply): Paycheck Protection Loan/Forgiveness, Covid Economic Injury Disaster Loan, Restaurant Revitalization Fund, Shuttered Venues Grant, Other SBA Disaster Loans, microloan, 7(a) or 504 guaranteed loan, 8(a) Certification, Other Contracting Certification, Other
Part III – Business Advisor
Business Advisor name (list multiple if appropriate)
Contact Hours (hours of assistance)
Prep Days (how many days taken to complete and submit application from first meeting)
Assistance Approved (dollar amount of loan/grant approved)
Part IV – Training Record
Information is provided by grantee.
Date of Training
Number of sessions
Total training hours
Title of Training
Live training or virtual
Location of Training
Total number Trained: include subtotals for Currently in Business, Not Yet in Business, People with Disabilities, Veterans, Women, LGBTQ, Race (American Indian or Alaska Native, Asian, Black or African America, Native Hawaiian or Other Pacific Islander, White), Ethnicity (Hispanic or Latino, not Hispanic or Latino)
Training Topic: Business start-up/preplanning, Business Plan, Business Financing/Capital Sources, Covid Financing Programs, International Trade, eCommerce, Business Financials/Cash Flow, Credit Counseling, Government Contracting, Disaster Preparedness/Recovery, Business Operations, Management, Marketing, Other
Participating Partners: SBA District Office, SBDC, SCORE, WBC, VBOC, Other
Language(s) training presented:
Paperwork Reduction Act: You are not required to respond to any collection of information unless it displays a currently valid OMB approval number. The total estimated annual burden for responding to this information collection is 20 minutes for grantees and 10 minutes for small business clients. Comments or questions on the burden estimate should be sent to U.S. Small Business Administration, Director, Records Management Division, 409 3rd Street. S.W. Washington, D.C. 20416 and/or SBA Desk Officer, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, DC 20503
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| Author | Clowes, Julie A. |
| File Modified | 0000-00-00 |
| File Created | 2021-05-14 |