Survey Assessment for Employee Retention Credits
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Type of Business
Primary Contact
Business Address
Does the business owner/s have any other business in which the owner has a 50% or greater interest?
Since the COVID-19 National Emergency Declaration on March 13th, 202, were operations fully or partially suspended due to a mandated shutdown?

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:

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.

Did the applicant receive funding through the Paycheck Protection Program (PPP)?

If the applicant received a first round of the PPP funding, what was the start and end date for the covered period?

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If the applicant received a second round of the PPP funding, what was the start and end date for the covered period?

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Were funds received by the applicant for the following programs?

Did the applicant receive a Research and Development Tax Credit?
Did the applicant receive credits from the Family First Act Wage/Family Leave Credit?
Veterans Tax Credit?
Any other Federal funding from COVID-19 reasons?
By 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.
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