Survey Assessment for Employee Retention CreditsFill out the form below or print and email your survey to info@ercfinders.com. Or, if you prefer, you can fax it to 504.617.6706.Print Survey Business Legal Name Type of Business C Corp S Corp Sole Proprietorship Partnership Non-Profit Other Primary Contact First Last Email Business PhoneBusiness Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Business TIN (EIN, SSN) Payroll Provider Business's Primary Activity Does the business owner/s have any other business in which the owner has a 50% or greater interest? Yes No If so, please provide the other business names, number of employees, and ownership percentages for each additional business:Since the COVID-19 National Emergency Declaration on March 13th, 202, were operations fully or partially suspended due to a mandated shutdown? Yes No Please describe government mandated shutdown orders below and provide start and end dates for those orders below and provide start and end dates for the orders:Shutdown Order Start Date Start Date Shutdown Order Start Date Start Date Shutdown Order Start Date Start Date Please provide total gross revenues, including interests, dividends, royalties, gain on sale of assets and annuities. Do not include anything from the Paycheck Protection Program.Quarter 1, 2019 Quarter 2, 2019 Quarter 3, 2019 Quarter 4, 2019 Quarter 1, 2020 Quarter 2, 2020 Quarter 3, 2020 Quarter 4, 2020 Quarter 1, 2021 Quarter 2, 2021 Quarter 3, 2021 Quarter 4, 2021 Did the applicant receive funding through the Paycheck Protection Program (PPP)? Yes No If PPP funds were received, what was the amount of the first loan? What was the amount of the first loan that was forgiven? If the applicant received a first round of the PPP funding, what was the start and end date for the covered period?Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY If PPP funds were received, what was the amount of the second loan? What was the amount of the second PP loan that was forgiven? If the applicant received a second round of the PPP funding, what was the start and end date for the covered period?Start Date MM slash DD slash YYYY End Date MM slash DD slash YYYY Were funds received by the applicant for the following programs?Did the applicant receive a Research and Development Tax Credit? Yes No Did the applicant receive credits from the Family First Act Wage/Family Leave Credit? Yes No Veterans Tax Credit? Yes No Any other Federal funding from COVID-19 reasons? Yes No Any additonal information:SignatureBy my signature above, I certify the information I have provided on and in connection with this form is true and correct to the best of my knowledge.Date MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.
