Nonprofit ERC Program

1) Business Name of ERC Applicant *

2) Name of person completing form *

3) What is the current Business Address of the business this form is being completed for? *

4) What is the current Mailing Address of the business this form is being completed for? *

5) Title of person completing this form *

6) Is your business a startup company and started operations on or after 2/15/2020? *

7) If Yes to previous question, did your combined gross revenue across all businesses you own exceed $1 million in either 2020 or 2021? *

8) Does your business operate from multiple locations? If yes, please share list of locations *

9) Did you file all of your 941s from Q2 2020 through Q3 2021? *

10) Payroll provider used, and if switched list the provider from before and now, and when switched *

11) How many full-time employees did you have in 2019? *

12) How many W2 employees (PT & FT) did you have in 2020? *

13) How many W2 employees (PT & FT) did you have in 2021? *

14) Does your business owe back taxes? If yes, how much? *

15) Are you behind on any of your payroll taxes? If yes, how much? *

16) Please provide ownership information of the business. Who are the owner(s) and provide the percentage of the business owned by each member. If multiple owners, please describe if any of the owners are related to each other. *

e.g. John Smith owns 50% of the business. Jane Smith owns 50% of the business. John and Jane are married.

17) Does the owner own other businesses located in the United States? *

18) Is there anyone related to the owner(s) employed in the business? If so, please name them as listed on the payroll. *

19) Did your business have a decline in GROSS revenue in ANY quarter in 2020 or 2021 compared to the same quarter in 2019? Please list approximate percentage drop in gross receipts. *

For example, the business had a decline in revenue 1st QTR 2021 compared ot the 1st QTR of 2019.

20) Are you able to provide documentation to support the above claims? Yes/No *

Either Quarterly Profit and Loss or Quarterly Income Statements will suffice.

21) Did your business experience any government mandates or orders to shut down during the 2020-2021 pandemic? *

22) Provide a description of how the business was subject to a government order to shutdown business operations. *

23) Provide the dates of when the business was subject to a government order to shutdown business operations. *

E.g., From 4/1/2020 to 10/15/2020

24) Provide any other information related to the govt shutdown order or questions you may have regarding eligibility. *

E.g., Subject to multiple orders: classroom subject to closure until XX/XX/XXXX, then class size reduction from XX/XX/XXXX to XX/XX/XXXX, etc.

26) If you received any of the above credits/govt funding, please list the amount, date received, as well as covered period (usually 8 or 24 weeks), & percentage used for payroll (60-80%). Please list as described below for each one received. *

E.g., recieved PPP round 1 funds of $50,000 in bank account on 4/6/2020. 24 week covered period 4/6/2020 to 9/21/2020. 75% used for payroll.

EIN # *

If you have any questions and would like to discuss your eligibility for the ERC, please provide Name, Relation to business, and Contact Information *

Alexis Smith, Owner, x@xxxxx.com (xxx) xxx - xxxx

Nonprofit ERC Program

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