SBA Form 641 Counseling Information Form

U.S. Small Business Administration

OMB Approval No.:3245-0324
Expiration Date: xx/xx/xxxx

Counseling Information Form

Client Number:
DUNS or SAM Number:
Location Code:
Initials of Data Inputter:

1. Organization _______________________________
2. Office City/State _________________________

PART I: Client Request for Counseling

3. Client Name (Name of the person completing the form/representative of the business)
(Last, First, MI)
5. Telephone
Secondary
Primary
7. Street Address/PO Box (give business address if currently in business) 8. City

4. Email
6. Country
9. State

10. Zip

+4

11. Client Agreement: I request business counseling service from an SBA Resource Partner, I authorize SBA or its agents 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 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 Resource Partners and host
organizations, arising from this assistance. I understand that any information disclosed will be protected to the extent permitted by law. (SBA or its agents will not provide your personal
information to commercial entities.)
Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from SBA Resource Partner. The information is collected to
help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet
Congressional and Executive Branch reporting requirements. The form should be submitted at the site of service to the counselor providing the service. Resource Partners will submit information
to SBA according to the terms of their notice of award.

Date:

Client Signature:

12. Participation in Surveys and SBA Communication: I agree to cooperate should I be selected to participate in surveys designed to evaluate SBA Resource Partner 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
13. Primary Counseling Sought (select 2-3 topics only)
eCommerce (using Internet to do
Marketing/Sales (promotion, market
Customer Relations
Business Start-up/Preplanning (How do I
business)
research, pricing, etc.)
Business Accounting/Budget
start a small business?)
Legal Issues (such as, Should I
Government Contracting (including
Business Financial/Cash Flow
Business Plan
incorporate?)
certifications)
Tax Planning
Business Financing/Capital Sources (such
International Trade
Disaster Planning/Recovery
Franchising
as applying for a loan, equity capital)
Intellectual Property Training
Cyber Security/Cyber Awareness
Buy/Sell Business
Business Operations/Management
Other
Credit Counseling
Technology
Human Resources/Managing Employees
Describe specific assistance requested in the space provided
____________________________________________________________________________________________
15. Gender
14. Race and Ethnicity (Mark all that apply)
Middle Eastern or North African
Male
American Indian or Alaska Native
Female
Native Hawaiian or Other Pacific Islander
Asian
Non-binary
White
Black or African American
Prefer to Self-Describe
Hispanic or Latino
__________________

18. Military Status

No military service

Member of the Reserve
Active Duty

Veteran
Service Disabled Veteran

16. Sexual
Orientation
LGBQ
Not LGBQ
Prefer to Self-Describe
__________________

17. Do you consider
yourself a person
with a disability?

Member of National Guard
Spouse of Military Member

Yes

No

Branch of Service

19. Referred by (Mark all that apply)
SBA District
Lender
Business Owner
SBA Web site

SBDC
SCORE
WBC
VBOC

Other Client
Educational Institution
Local Economic Development Official
Chamber of Commerce

Other
Magazine/Newspaper
USEAC
Word of Mouth
Boots to Business
Television/Radio
Internet (please indicate website)

PART II: Client Intake (to be completed by all Clients)

20. Are you currently in business?

Yes

No (STOP form is complete)

Undetermined (STOP form is complete)

21. Company/Business Name

Yes
No
22. Are you currently exporting?
If yes to 22, please go to Appendix A on page 3 to indicate the markets to which your company currently exports (mark all that apply).
23. Type of Business (choose primary category)
Mining
Utilities
Information
Construction
Retail Trade

Manufacturing
Finance and Insurance
Wholesale Trade Public
Administration
Educational Services

24. Business Ownership – What percentage of
your business is woman owned?
0.00%
__________%
Woman Owned

27a. No. of Employees

Real Estate and Rental and Leasing
Health Care and Social Assistance
Accommodation and Food Services
Arts, Entertainment and Recreation
Transportation Warehousing

25. Conducting Business Online

Professional, Scientific and Technical Services
Management of Companies and Enterprises
Agriculture, Forestry, Fishing and Hunting
Administrative and Support
Waste Management & Remediation Services
Other Services (except Public Administration)

26. 8(a) Certified

No

Yes

28a. For your most recent full business year, what
were your: Gross Revenues/Sales

+Profits/-Losses
27b. Of total employees, how many are
28b.
Amount
of
your
Gross Revenues/Sales
engaged in the exporting aspect of your
related to exporting $
business:
SBA Form 641 (XX/XX/XXXX)

1

Yes

No

29. Legal Entity
Sole Proprietor

Corporation

S-Corporation

Partnership

Other

________________________________

LLC

U.S. Small Business Administration
Counseling Information Form

OMB Approval No.:3245-0324
Expiration Date: xx/xx/xxxx
Client Number:
DUNS or SAM Number:
Location Code:
Initials of Data Inputer:
Funding Source:

Part III: Counselor Record

30. Client Name (please use the client who will be counseled)
(Last, First, MI)
32. Telephone
Primary
Secondary
34. Street Address/P.O. Box
No
Yes
38a. Is the client verified to be in business?

31. Email
33. Country
35. City

37. Zip

+4

Yes
No
(New Business start attributable to Resource Partner assistance)

Undetermined

38b. Date Business Started

36. State
39a. Reportable Impact?

39b. Date of Reportable Impact
41. Is the client currently exporting?

40. Client Company/Business Name

Yes

No

If yes to 41, please go to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all that apply).
43a. As of the most recent full business year, what were the client's annual:
42a. Total No. of Employees
42b. Total No of Employees Engaged in Exporting

Gross Revenues/Sales _____________________ +Profits/-Losses

43b. How much of your client's Gross Revenues/Sales were related to
exporting?

44. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)

Certifications
8(a)
WOSB
Hubzones
EDWOSB
SDB
SDVOSB
VOSB
Other

SBA Loan Amount
Non-SBA Loan Amount
Amount of Equity Capital Received
No. of Government Contracts/Subcontracts
Annual Value of Government Contracts/Subcontracts Received

No. of Non-SBA Loans ________

No. of SBA Loans ________

SBA Financial Assistance
Economic Impact Disaster Loan (EIDL)
Export Express
Export Working Capital
Community Advantage
Micro Loan
SBIR
Other (SBIR, SBIC, 7(a) 504, etc)

No. of Equity Transactions ________

45. What was the nature of the counseling you provided the client? (choose primary category)
Business Start-up/Preplanning
Business Plan
Business Financing/Capital Sources
Business Operations/Management
Human Resources/Managing
Employees

Customer Relations
Credit Counseling
Business Accounting/Budget
Business Financial/Cash Flow
Tax Planning
Marketing/Sales

Government Contracting
Franchising
Buy/Sell Business
Technology
eCommerce

Cyber Security/Cyber Awareness
Legal Issues
International Trade
Intellectual Property Training
Disaster Planning/Recovery
Other

Please specify other counseling provided

46. Referred Client to (mark all that apply)
WBC
SCORE
SBDC
VBOC

APEX Accelerator
DFC (OPIC)
USEAC

Department of Agriculture
Department of State
SBA Disaster Assistance

47. Language(s) Used

Department of Commerce/Commercial
Services Export/Import Bank
State Trade Agency
Other:

48. Counselor(s) Name (If multiple counselors, list lead counselor first and 49. Counseling Date
separate each additional counselor name by a semi-colon):

English
Spanish

SBA District Office
SBA Office of International Trade (OIT)
SBA Capital Access (PPP)
U.S. Trade and Development Agency

Other (specify)

50. Type of Session
Training
Face-to-Face
Telephone

Online
Prepare Only
Update Only

51a. Contact Hours
Total contact hours
that a client received

51c.Travel Hours
51b. Prep Hours
Total amount of preparation spent by Total amount of time it takes to travel to a
all of the counselors for a client
client's location for counseling

52. Counseling Notes:

Please note: The estimated burden for completing this form is 20 minutes. You are not required to respond to any collection information unless it displays a current valid OMB
approval number. Comments on the burden should be sent to: [email protected]. Alternatively, inquiries can be sent to U.S. Small Business Administration, Attn: Director,
Records Management Division, 409 3rd Street, SW, Washington, DC 20416 and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room
10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 641 (XX/XX/XXXX)

2

U.S. Small Business Administration

Counseling Information Form

OMB Approval No.:3245-0324
Expiration Date: xx/xx/xxxx
Client Number:
Location Code:
Initials of Data Inputter:

Privacy Act Statement: The primary purpose for collecting this information is to help SBA's continuing improvement of business counseling
programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and
Executive Branch reporting requirements. Providing the requested information is required to obtain and/or retain benefits. Routine uses of this
information are established in SBA’s Privacy Act System of Record, SBA 11, Entrepreneurial Development--Management Information System
published on November 3, 1999, at 64 FR 59819.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 (FOIA). In addition, to the extent permitted under FOIA, confidential business
information (CBI) will only be disclosed to contractor or Agency personnel assigned to work on these programs. Any Person concerned with the
collection of this information, disclosure or routine use under the Privacy Act may contact the Freedom of Information/Privacy Acts Office, Small
Business Administration, 409 3rd St., S.W., Washington, D.C. 20416.

Appendix A to Questions 22. & 41.

If your company is currently exporting, please indicate the countries to which your company exports. Identify all that apply referencing the
attached Country List Supplement document. To access the supplemental document, please open this form in Adobe Reader.
For information on current U.S. trade sanctions, please visit the Office of Foreign Assets Control: Sanctions Programs and Country
Information, https://www.treasury.gov/resource-center/sanctions/Programs/Pages/Programs.aspx

Countries

Subcontractor for Exporter
Sell to Fill-Freight

Appendix B
Definitions:
Middle Eastern or North African - This category includes individuals with origins in any of the original peoples of the Middle East or
North Africa, including, for example, Lebanese, Iranian, Egyptian, Syrian, Moroccan, and Israeli.
In Business - A business that has completed required registration(s), if applicable, with the local, state, and/or Federal government (e.g., DBA
registration, get a business license, agency issued tax identifications, etc.) AND at least one of the following:
o Generating revenue- Has documented a transaction from the sale of a product or professional or personal service for the purpose of
gain or profit.
o Accessing Capital- Has acquired debt or Equity Infusion to pursue business operations, for example, to purchase inventory,
equipment, building, business, etc.
 Debt includes SBA Loans and Non-SBA loans. Non-SBA loans includes all forms of capital debt, for example, consumer
debt products used specifically for the business, lines of credit, and other revolving debt facilities/instruments.
 Equity Infusion includes all forms of investments from all sources, for example, angel investors, crowd funding, family
contributions, owners’ capital contributions, grants and other capital contributions not associated with equity.
o Acquired Resources - Has hired and/or compensated an employee(s) including the business owner/sole proprietor or contracted with
an independent contractor(s) to perform essential business functions.
o Incurring expense- Has incurred business expenses in the operation of a business.
Reportable Impact - Counselor determines that the Resource Partner provided assistance with the business start. When the Reportable
Impact indicator is marked Yes, it will be counted as a new business start if no other previous session has reported the same client to have
Reportable Impact for that business.
Session Type: Training - The Training session type on the 641 may be used to record individual attendance at training sessions hosted by
Resource Partners. Training courses and aggregated training attendance information is reported on the 888 form.
SBA Form 641 (XX/XX/XXXX)

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