Purpose & Disclosure
This form is used to evaluate business eligibility for nonprofit assistance and ensure compliance with nonprofit regulations. Submission does not guarantee assistance.
Business Information
Legal Business Name (required)
DBA (if applicable)
Business Address
City / State / ZIP
Email Address (required)
Phone Number (required)
Business Structure
Business Type
Sole ProprietorLLCCorporationPartnershipNonprofitOther
EIN (if applicable)
Year Established
Primary Contact Person
Full Name (required)
Title / Role
Email (required)
Phone (required)
Business Operations
Industry / Sector
Number of Employees
12–56–1011+
Estimated Annual Revenue
Under $50k$50k–$100k$100k–$250k$250k+
Financial Challenges
Check all that apply
Cash FlowBusiness DebtTaxes / IRSPayrollOperating ExpensesStartup CostsOther
Estimated Total Business Debt (if known)
Support Requested
Type of support requested
Financial EducationBusiness PlanningSustainability GuidanceDebt AssistanceEmergency Support
Describe your business need
Compliance & Certification
Information provided is accurate.
Assistance is not guaranteed.
No ownership, equity, or profit interest is created.
Funds must be used for stated purposes.
Support is subject to nonprofit policy and availability.
Authorized Signature
Authorized Representative Name (required)
Title
Date
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