Civil Unrest Impact Form

Civil Unrest Impact Form
DCEO is working diligently to secure access to helpful resources for businesses throughout the State of Illinois at this time.

We are working with the U.S. Small Business Administration (SBA) who can provide targeted, low-interest loans to small businesses and non-profits that have been severely impacted by civil unrest in counties who have received a disaster declaration through SBA.

As a part of this process, we need to collect information from businesses that have been negatively impacted.

The information submitted through this form will assist us in requesting a disaster declaration from SBA.

Please note: This form is not an application for funding and information obtained will not be used for or against you if you decide to later submit an application for a loan through SBA. As we are able to secure declarations by county, we will send out information regarding loans (including links to applications) and businesses that fill out this form will receive this information directly.

If your business has experienced an impact due to the civil unrest, including property damage or other losses due to civil unrest closure, we ask that you please take a moment to fill out this form so we can provide the necessary information to SBA.

Please feel free to share this link with any other businesses you know may be impacted throughout the state. Once we have collected a sufficient number of forms to receive a declaration in every impacted county, this form will be suspended.

If you are a business that is not yet connected with our Small Business Development Centers for business assistance and planning, we encourage you to reach out to them. Their information can be found here in addition to contact information for our Office of Minority Economic Empowerment Team and Regional Economic Development Team.

Thank you so much for your assistance.
What type of injury has your business experienced as a result of civil unrest? (Please select all that apply.)
Name of Business
Name of Business Owner

First NameLast Name
Type of Business
Which of the following apply to your business? (Please select all that apply.)
Your business has been identified as a minority-owned. Please select all that apply below.

Other
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
County
Phone Number

Area CodePhone Number
Email
example@example.com
Estimated Adverse Economic Impact due to Civil Unrest
When did the impact start?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter the date that the economic impact to your business due to the disaster started or is estimated to start. Economic impact can be defined as a decrease in revenues from normal levels resulting in decreased gross profit. *Please note* The earliest date that can be chosen is 5/25/2020.
When did the impact end?

MonthDayYear
2 digit month, 2 digit day, 4 digit yearEnter the date that revenues and gross profits returned to normal levels. This date may be in the future and will require an estimate.
What were your business' revenues during that period? ($)
Enter the business’ revenues between the two dates you showed.
What were your business' revenues during the same period of the prior year? ($)
Enter the business’ revenues between the same two dates of the previous year. If this amount is smaller than the one above, please check your work. Economic injury would be reflected by showing a "loss" or smaller value above.
Amount of business interruption insurance received or anticipated, if any ($):
If you have business interruption insurance to cover losses due to the disaster, enter the amount received or anticipated. Enter zero if none.
Provide a brief explanation of what adverse economic effects the disaster had on your business:
Enter a brief narrative explaining how the disaster affected your business’ revenues and operations.
How many people did you employ PRIOR TO the disaster?
Enter the number of employees, including management and part-time employees, of the business prior to the date of the disaster.
How many people did you employ AFTER the disaster?
Enter the number of employees, including management and part-time employees, of the business after the end of the disaster. This may require an estimate.
Property Damage
Are you an owner or renter of the property?
Do you have a mortgage?
Do you have a Standard Business Owners Insurance Policy (BOP)?
Please provide the status of the property.
What is the fair market value of the property (building)? ($):
Enter the fair market value of the property, in dollars, if owned by the business or an owner of the business. If not applicable, please enter "0".
What is the estimated dollar loss to property (building)? ($):
Enter the estimated loss, in dollars, to the building occupied by the business, if owned by the business or an owner of the business. If not applicable, please enter "0".
What is the estimated fair market value of contents (machinery and equipment, furniture and fixtures, inventory, leasehold improvements, etc)? ($):
Enter the fair market value, in dollars, of the contents of the business' building. If not applicable, please enter "0".
What is the estimated dollar loss to contents (machinery and equipment, furniture and fixtures, inventory, leasehold improvements, etc)? ($):
Enter the estimated loss, in dollars, to the contents of the business' building. If not applicable, please enter "0".
Insurance recovery received or anticipated for property damages ($):
Enter the insurance recovery received or expected for disaster damage to the building, if applicable. If not applicable, please enter "0".
Insurance recovery received or anticipated for contents ($):
Enter the insurance recovery received or expected for disaster damage to the contents, if applicable. If not applicable, please enter "0".
Please provide a brief explanation of the damages.
Please include any photos of the damages you have.

Browse Files

Cancelof
Please include any links to photos of the damages you have.
Signature of Business Owner/Representative
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit year
Business or Home
Should be Empty:

Civil Unrest Impact Form

Estimated Adverse Economic Impact due to Civil Unrest

Property Damage