SBA Form 3516 - Intake
SBA Form 3516

OMB Control No: 3245-0423
Expiration date: 12/31/21

 
Community Navigators Pilot Program Client and Program Information Form

Use of Information Collected: Information collected from SBA Form 3516 will only be published in summary or aggregate form as a means of providing SBA management officials, Congress, the White House and OMB with reports on program activity and participant outcomes. SBA expects to produce annual reports to the White House, OMB and Congress on the impact of the Community Navigator Pilot Program leveraging aggregate data to illustrate program objectives and outcomes have been met. Please note, SBA may match Form 3516 information with other data sets for program evaluation purposes. In all cases, SBA will protect individual privacy and confidentiality and only aggregate and summary data would be published.

Privacy Act Statement (5 U.S.C. 552a)

The information in this form is provided by individuals and businesses seeking assistance from a Community Navigator. The information is collected to help SBA’s oversight and management of the Community Navigator Program, ensure program equity and integrity and to meet Congressional and Executive Branch reporting requirements.  Some of the information collected is voluntary however it is important to SBA to help assess how well the program is serving different communities and to ensure equitable treatment of all people. Only you, the Community Navigator from which you are seeking assistance and SBA will be privy to the individualized confidential and proprietary information.  Any personal information collected, including the client’s Social Security Number, will be protected to the extent permitted by law, including the Privacy Act of 1974 and the Freedom of Information Act.   SBA has instituted procedures to protect confidentiality and only aggregate and summary data will be provided in public reports to the Congress and the White House.

Providing your social security number is voluntary.  SBA uses your social security number to verify whether you received SBA assistance (financial or otherwise).  You are asked to voluntarily provide your social security number to assist SBA in distinguishing you from other individuals with the same or similar name, or other personal identifiers. Not providing your social security number will not affect any right, benefit or privilege to which you are entitled. This request is permitted under EO 9397.
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Part I: Client Contact Information
This section is required for all counseling engagements
1. Client Name (Last, First, MI) *
2. Email *
3. Phone number
4. Business Street Address, City, State, Zip code (personal address if no business address)
Part II: Client Demographic Information
This section is required for first time counseling engagements

Demographic information should be provided for the primary business owner if the business has multiple owners. Providing the information in this section is voluntary but will be used by SBA to assess how well the program is serving different communities and to ensure equitable treatment of all people.
5. Race (mark one of more)
6. Ethnicity:
Clear selection
7. What is your gender identity:
Clear selection
8. Do you identify as:
Clear selection
9. Do you identify as:
Clear selection
10. Do you consider yourself a person with a disability?
Clear selection
11. Military Status:
Clear selection
Part III: Client Business Information
This section is required for first time counseling engagements, and for subsequent meetings when there is a change or milestone.
12. Are you currently in business? If no, skip to question 29: Nature of Assistance Sought.
Clear selection
13. Name of Business (If applicable)
14. Date Business Started
MM
/
DD
/
YYYY
15. Taxpayer ID# (Providing your Social Security Number is voluntary.  SBA uses your Social Security Number to verify whether you received SBA assistance (financial or otherwise).  Not providing your Social Security Number will not affect any right, benefit or privilege to which you are entitled.)
16. Is Taxpayer ID# a Social Security Number?
Clear selection
17. Type of Business:
18. Legal Entity:
19. Number of Employees (Full Time)
20. Number of Employees ( Part-Time)
21. For your most recent business year, list:  Gross Revenue
22. For your most recent business year, list: Profits
23. For your most recent business year, list: Losses
24. Is this a woman-owned business? (A business is woman-owned if at least 51% of the business or stock is owned by one or more women and the management and daily business operations are controlled by one or more women.)
Clear selection
25. Have you applied for or received any SBA services in the past 5 years?
Clear selection
26. If you received SBA services, which programs?
27. Do you conduct business in a language other than English?
Clear selection
28. If you conduct business in a language other than English, which language(s)?
Part IV: Nature of Assistance
This section is required for all counseling engagements
29. Nature of Assistance Sought:
30. What is a dollar amount for loan/grant sought? (If applicable)
31. Are you requesting assistance in English?
Clear selection
32. Are you requesting language assistance? If yes, which languages?
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