SBA Form 3516 Community Navigators Pilot Program Client and Program In

U.S. Small Business Administration

OMB Control Number: 3245-0423
Expiration Date: 12/31/21

Form 3516
Community Navigators Pilot Program Client and Program Information Form

I request business counseling service from the Small Business Administration (SBA) or Community Navigator. I agreed to cooperate should I be selected to
participate in surveys designated to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings
regarding SBA products and services (Yes
No
). I understand that any information disclosed will be held in strict confidence. (SBA will not provide your
personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that
the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from
this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that
of its Community Navigator and host organizations, arising from this assistance.
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.

Client Signature:

Date:

Part I: Client Contact Information This section is required for all counseling engagements

Client Name: (Last, First, MI)
Email:

Telephone:

Business Address: Street, City, State, Zip
Part II: Client Demographic Information This section is required for first time counseling engagements

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.

Prefer not to say
Race:
American Indian or Alaska Native Asian Black or African American
Prefer
to
self-describe
White
Native Hawaiian or Other Pacific Islander
What is your gender identity?
Female
Do you consider yourself a person with a disability?
Yes
No
Male
Nonbinary
Prefer not to say
Prefer to self-describe
Intersex
Transgender
Do you identify as:
Both
Neither
Prefer not to say
Prefer to self-describe
Military Service:
No Military Service
Veteran
Spouse of Military Member
Active Duty
Service-Disabled Veteran

Bisexual
Gay/ Lesbian
Do you identify as:
Heterosexual
Prefer not to say
Prefer to self-describe
Ethnicity:
Hispanic or Latino
Not Hispanic or Latino
Prefer not to say
Prefer to self-describe

Part III: Client Business Information This section is required for first time counseling engagements, and for subsequent
meetings when there is a change or milestone

Are you currently in business?
Name of Business:

Yes

Taxpayer ID #:
a. Is this a Social Security Number?

No

Yes

Date business started:

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.)

Legal Entity:
Sole Proprietorship
Corporation
Partnership

S-Corporation
LLC
Other

Total Number of Employees:
Part Time:

Full Time:

U.S. Small Business Administration

Form 3516

OMB Control Number: 3245-0423
Expiration Date: 12/31/21

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 Services
Arts
Entertainment & Recreation
Transportation & Warehousing
Professional
Scientific & Technical Services
Management of Companies & Enterprises
Agriculture
Forestry
Fishing
Administrative & Support
Waste Management & Remediation Services
Other Services (except Public Administration)
For your most recent business year list:
Gross Revenue:
Profits:
Losses:
Have you applied for or received any SBA services in the last 5 years?
Yes
No
a. 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
7(a) or 504 Guaranteed Loan
8(a) Certification
Other Contraction Certification
Other (specify)
Do you conduct business in a language other than Is this a woman-owned business? (A business is woman-owned if
at least 51% of the business or stock is owned by one or more women and the
English?
Yes
No
management and daily business operations are controlled by one or more women.)
a. If yes, which languages
Yes
No
Part IV: Nature of Assistance: This section is required for all counseling engagements

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?

Are you requesting language assistance?
Yes
No
a) If yes, which languages

Part V: Business Advisor Information This section is required for all counseling and training engagements

Name of Entity Providing Service:
City/ State of Office Location:

Business Location:

Urban

Business Advisor Name: (List multiple if appropriate)

Rural

Contact Hours:

Prep Days: (How many days taken to complete and Assistance Approved: (Dollar amount of loan/ grant
submit application from first meeting)
approved)

U.S. Small Business Administration

OMB Control Number: 3245-0423
Expiration Date: 12/31/21

Form 3516

Part VI: Training Record: This section is required for all training engagements
Date of Training:
Total training Hours:
Number of Sessions:
Title of Training:
Type:
Live
Virtual
Location of Training:
Total Number Trained:
Race:
American Indian or Alaska Native
Currently in Business
Asian
Not Yet in Business
Black or African American
People with Disabilities
Native Hawaiian or Other Pacific Islander
Veterans
White
Women
Ethnicity:
LGBTQIA+
Hispanic or Latino
Not Hispanic or Latino

Training Topic:
Business Plan
Business Start-up/ Preplanning
Business Financing/ Capital Sources
Covid Financing Programs
Government Contracting
Participating Partners:
SBA District Office
Language(s) used to conduct training:

International Trade
Disaster Preparedness/ Recovery
Business Financials/ Cash Flow
Credit Counseling
Other (specify)
SBDC

SCORE

WBC

Marketing
eCommerce
Business Operations
Management

VBOC

Other

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.