SBA Form 3516
OMB Control Number 3245-XXX
Expiration Date:
Community Navigators Pilot Program Client and Program Information Form
Use of Information Collected: Information collected from SBA Form 3516 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.
Part I - Business Information (completed by client). This information is required to engage Navigator services.
Client Name (Last, First, MI)
Name of Business (if applicable)
Telephone
Business Street Address, City, State, Zip (personal address if no business address)
Are you currently in business? Yes/no
Date Business Started
Taxpayer ID #
Is this a Social Security Number? Yes/no
(Providing your Social Security Number is voluntary. SBA uses your Social Security Number to verify whether you received SBA assistance (financial or otherwise). Not providing your Social Security Number will not affect any right, benefit or privilege to which you are entitled.)
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)
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
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 II - Business Information (completed by client). Demographic information should be provided for the primary business owner if the business has multiple owners. Providing the information in this section is voluntary but will be used by SBA to assess how well the program is serving different communities and to ensure equitable treatment of all people.
Race (mark one or more): American Indian or Alaska Native, Asian, Black or African America, Native Hawaiian or Other Pacific Islander, White, prefer to self-describe, prefer not to say
Ethnicity: Hispanic or Latino, not Hispanic or Latino, prefer to self-describe, prefer not to say
What is your gender identity? female, male, nonbinary, prefer to self-describe, prefer not to say
Do you identify as: intersex, transgender, both, neither, prefer to self-describe, prefer not to say
Do you identify as: bisexual, gay/lesbian, heterosexual, prefer to self-describe, prefer not to say
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
Is this a woman-owned business? Yes/no (A business is woman-owned if at least 51% of the business or stock is owned by one or more women and the management and daily business operations are controlled by one or more women.)
Do you conduct business in a language other than English? If yes, what language(s)?
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?
Part III – Business Advisor (completed by business advisor)
Name of Entity Providing the Service
City/State of Office Location
Business Advisor name (list multiple if appropriate)
Is business located in urban/rural location? Urban/rural
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 (completed by business advisor)
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 (please specify)
Participating Partners: SBA District Office, SBDC, SCORE, WBC, VBOC, Other
Language(s) used to conduct training:
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
Privacy Act Statement (5 U.S.C. 552a)
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. Some of the information collected is voluntary however it is important to SBA to help assess how well the program is serving different communities and to ensure equitable treatment of all people. Only you, the Community Navigator from which you are seeking assistance and SBA will be privy to the individualized confidential and proprietary information. Any personal information collected, including the client’s Social Security Number, 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 the White House.
Providing your social security number is voluntary. SBA uses your social security number to verify whether you received SBA assistance (financial or otherwise). You are asked to voluntarily provide your social security number to assist SBA in distinguishing you from other individuals with the same or similar name, or other personal identifiers. Not providing your social security number will not affect any right, benefit or privilege to which you are entitled. This request is permitted under EO 9397.
| File Type | application/vnd.openxmlformats-officedocument.wordprocessingml.document |
| File Modified | 0000-00-00 |
| File Created | 2021-06-14 |