Request edit access
COVID-19 Minority Business Fund Survey and Application
We understand this is a climate of uncertainty and are working to understand your needs and how we can best help. This form is for internal purposes only and your privacy will be respected, however you have the option to keep this anonymous. If a question isn't relevant to you/your business, please leave blank.

If selected you might be required to work with a Small Business service provider with Technical Assistance and provide additional information including but not limited to: 2018 or 2019 tax returns, and interim 2020 financial information.
Sign in to Google to save your progress. Learn more
Business Name
Contact Email
How long has your business been open for?
Do you own or lease your space?
Clear selection
If you lease, when does your lease expire?
MM
/
DD
/
YYYY
How many people does your business employ?
Clear selection
Please check all which apply to you:
Business Industry
Clear selection
Are you currently a member of a local incubator or accelerator?
Clear selection
If so, please list which one(s)
What is the current status of your business?
Does your business have an online sales component?
Clear selection
Have you currently applied for an SBA Disaster Loan?
Clear selection
If yes, when did you apply?
MM
/
DD
/
YYYY
If yes, how much did you apply for?
If you did not choose to apply, please explain why.
Have you currently applied or are planning to apply for the Paycheck Protection Program (PPP)?
Clear selection
If yes, how much did you (or are you planning to) apply for?
If yes, when did you apply?
MM
/
DD
/
YYYY
If you did not choose to apply, please explain why.
If you have or are currently applying for an SBA loan, please list any local resources (i.e. SCORE, HCDC, Regional Chamber's helpline) which have helped you navigate the SBA loan process.
Please list other funding (loans, grants, etc.) outside of SBA loans you have received and/or applied for related to COVID-19. Please include the organization name and amount. Note: This includes if you've received funding via the Cincy Card Connection program.
How many employees have you had to layoff specifically due to COVID-19?
How many employees have you had to furlough specifically due to COVID-19?
Please check what assistance you have received through your landlord:
If your monthly rent was deferred, what date was it referred to?
MM
/
DD
/
YYYY
Who is your current insurance provider?
Does your insurance policy cover business interruption as a result of Covid-19?
Clear selection
Once Ohio's "Stay at Home" order is discontinued, what would be the estimated total cost associated with reopening your brick and mortar business? Please state the bare minimum in funds needed to officially reopen the doors to your brick & mortar space.
What would reopening funds be used for? Please select all those which apply and rank.
Most Important 1
Column 2
Column 3
Column 4
Column 5
Least Important
N/A
Rent
Ordering supplies & inventory
Recruiting staff
Rehiring staff
Marketing
Utilities
General maintenance
Clear selection
Any additional needs for "reopening" funds which were not mentioned above?
If business disruption continues at the current rate, how soon will your business be at risk of closing permanently?
Clear selection
From your point of view, what types of assistance would be most helpful to your business?
Please note any additional ways we could provide assistance or any comments & concerns here:
Submit
Clear form
Never submit passwords through Google Forms.
This form was created inside of MORTAR Cincinnati.

Does this form look suspicious? Report

Google Forms