/ Economic Impact Survey
IllinoisSmallBusinessDevelopmentCenter
Illinois Eastern Community Colleges /
Funded in part through a cooperative agreement with SBA

PART I: Client Information:

1. Client Name (last, First, MI): / 2. Company Name:
3. Email Address:

Updated Client Information Only In 3 through 13

3. Telephone:
Primary:Secondary: / 4. Fax Number:
5. Street Address/P.O. Box: / 6. City: / 7. State: / 8. Zip Code: / 9. Zip +4:
10. Is the client currently in business:
Yes No / 11. Month & Year Business Started: / 12. Total No. of Employees: (full & PT) / 13. As of the most recent counseling date and for the most recent year, what are the client’s annual:
Gross Revenues/Sales $______
+Profits/-Losses $______

PART II: ECONOMIC IMPACT:

16. Milestone: 8(A) Status Obtained Jobs Created – How many? ______Entered a Joint Venture
Date: Date: Date:
Bought Business Copyright Obtained Jobs Retained – How many?______Success Story
Date: Date: Date: Date:
Business Expansion Trademark Obtained Change in Profits - $ Amount ______Other
Date: Date: Date: Date:
Sold the Business Patent Obtained Change in Sales - $ Amount ______
Date: Date: Date:
Started Business EDI Implementation Changed Legal Form Sole Proprietorship Partnership Other
Date: Date: Date:Corporation S-Corporation LLC

PART III: CAPITAL FORMATION:

17. Capital Formation: Challenge Grant Commercial (Bank) Loan State Capital Access Loan
$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date:
Contract for Deed Grant Illinois Facilities Fund State Minority (Women) Loan (Direct)
$ Amount ______$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date: Date:
Line of Credit Micro-Loan Other Equity Investment State Minority (Women) Loan (Participating)
$ Amount ______$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date: Date:
Other Federal Loan Owner Investment Revolving Loan Funds State Small Business Loan (Direct)
$ Amount ______$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date: Date:
SBA 502 504 Loan SBA 7(A) Guaranteed Loan State Small Business Loan (Participating)
$ Amount ______$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date: Date:
SBA Contract Loan SBA Greenline Loan SBA Loan SBA Export Working Capital
$ Amount ______$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date: Date:
SBA LoDoc Loan SBA Micro Loan SBA Prequalification SBA Small Loan Express
$ Amount ______$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date: Date:
Stock Investment Venture Capital Homeland Security Innovative Product Grant
$ Amount ______$ Amount ______$ Amount ______
Date: Date: Date:
18. Notes:

The results indicated above can be attributed to the assistance received from the IllinoisSmallBusinessDevelopmentCenter at (insert center name)
Client Signature:Date:
ANY CHANGES TO THIS FORM OR THE USE OF ANY OTHER INTAKE FORMS MUST HAVE PRIOR WRITTEN APPROVAL OF THE SMALL BUSINESS DEVELOPMENT CENTER STATE DIRECTOR Updated 8/3/2009