SBA Form 3516 Community Navigators Pilot Program Client and Program In

U.S. Small Business Administration

Form 3516

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

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.
Purpose of Collection: The information in this form is provided by the Community Navigator grantees and the individuals and businesses seeking assistance from
such grantees. SBA is collecting this information for purposes of its oversight and management of the Community Navigator Program authorized under Sec. 5004 of
the American Rescue Plan Act of 2021, and to ensure program equity and integrity. Information collected 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. Except where indicated otherwise, collection
of the information is required to comply with the terms of the Community Navigator award and is important to SBA to help assess how well the program is serving
different communities and to ensure equitable access to the program. Navigators will submit information to SBA according to the terms of their notice of award.

Client Signature:

Date:

Part I: Client Contact Information This section is required for all counseling engagements (completed by client)
Client Name: (Last, First, MI)
Email:
Telephone:
Business Address: Street, City, State, Zip
Part II: Client Demographic Information This section is for first time counseling engagements (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 American
Native Hawaiian or Other Pacific Islander
White
What is your gender identity?
Female
Prefer not to say
Male
Prefer to self-describe
Nonbinary
Do you identify as:
Intersex
Prefer not to say
Transgender
Prefer to self-describe
Both
Neither

Prefer not to say
Prefer to self-describe

Do you consider yourself a person with a disability?
Yes
No

Do you identify as:
Bisexual
Gay/ Lesbian
Heterosexual

Prefer not to say
Prefer to self-describe

U.S. Small Business Administration

Form 3516

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

Military Service:
Ethnicity:
No Military Service
Hispanic or Latino
Not Hispanic or Latino
Veteran
Prefer not to say
Spouse of Military Member
Prefer to self-describe
Service-Disabled Veteran
Active Duty
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 (completed by client)
Are you currently in business?
Yes
No
Date business started:
Name of Business:
Taxpayer ID #:
a. 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.)

Total Number of Employees:
Legal Entity:
Part Time: _____
Full Time:_____
Sole Proprietorship
S-Corporation
Corporation
LLC
Partnership
Other
Type of Business:
Mining
Public Administration
Arts
Utilities
Educational Services
Transportation & Warehousing
Information
Real Estate, Rental, & Leasing
Professional
Construction
Health Care & Social Assistance
Scientific & Technical Services
Retail Trade
Accommodation & Food Services
Fishing
Manufacturing
Administrative & Support
Finance & Insurance
Entertainment & Recreation
Wholesale
Management of Companies & Enterprises
Agriculture
Waste Management & Remediation Services
Forestry
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
Other SBA Disaster Loans
Covid Economic Injury Disaster Loan
7(a) Disaster Loans or 504 Guaranteed Loan
Restaurant Revitalization Fund
8 (a) Certification
Shuttered Venues Grant
Other Contracting Certification
Other (specify)

U.S. Small Business Administration

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

Form 3516
Do you conduct business in a language other than
English?
Yes
No
a. If yes, which languages

Is this a woman-owned business? (A business is womanowned 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.)
Yes

No

Part IV: Nature of Assistance: This section is required for all counseling engagements (completed by client)
Nature of Assistance Sought:
7(a) Loan
Paycheck Protection Loan/Forgiveness
State/ Local Grant
504 Loan
Covid Economic Injury Disaster Loan
Disaster Preparedness
Microloan
Restaurant Revitalization Fund
Assistance Starting a Business
Export Loan
Credit Counseling/Financial Literacy
Shuttered Venues Grant
Other Loan
Other SBA Disaster Loans
Other
Business TA
SBA Contracting Certification
Other Grant
Non-Governmental Contracting Certification
Other TA
Other Federal/State/Local Contracting Certification
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
(completed by advisor)
Name of Entity Providing Service:

Date of Counseling:

City/ State of Office Location:

Business Advisor Name: (List multiple if appropriate)

Business Location:
Urban
Rural

Contact Hours:

Prep Days: (How many days taken to complete and
submit application from first meeting)

What is dollar amount of loan/
grant sought? (for submitted
application)
Assistance Approved: (Dollar amount of loan/grant
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 (completed by advisor)

Date of Training:
Title of Training:
Location of Training:
Total Number Trained:
Currently in Business
Not Yet in Business
People with Disabilities
Veterans
Women
LGBTQIA+

Total training Hours:
Type:
Race:

Live

Number of Sessions:
Virtual

American Indian or Alaska Native
Asian
Black or African American
Native Hawaiian or Other Pacific Islander
White

Ethnicity:
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)
The information you provide will not be disclosed outside of the SBA, except with your consent, and as otherwise allowed by the Privacy Act of 1974, 5 U.S.C. §552a,
or unless the information is subject to disclosure under the Freedom of Information Act. 5 U.S.C. §552. The Privacy Act authorizes SBA to make certain “routine uses”
of information protected by that Act, which are set forth in SBA’s Systems of Records Notice 11 – Entrepreneurial Development Management Information System, 74
FR 14889, 14901 (https://www.govinfo.gov/content/pkg/FR-2009-04-01/pdf/E9-7050.pdf). 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.