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ERC
Client Questionnaire
Part 1: Company Information
Business Name (Legal Entity Name)
Trade Name
EIN#
Business Location
Phone
Email
Business Description/Industry
Owner #1
Ownership %
Owner #2
Ownership %
Owner #3
Ownership %
Payroll Provider
Please Select
If "Other"
Do any employees have Employee Pre-Tax Health expenses deducted from their gross wages?
*
Yes
No
Part 2: Eligible Employer Test
***Please skip this section if you have or will provide item (Gross Receipts) from the Standard Documentation Request***
Q1 2019 (Jan 1 - Mar 31)
Q2 2019 (Apr 1 - Jun 30)
Q3 2019 (July 1 - Sep 30)
Q4 2019 (Oct 1 - Dec 31)
Q1 2020 (Jan 1 - Mar 31)
Q2 2020 (Apr 1 - Jun 30)
Q3 2020 (July 1 - Sep 30)
Q4 2020 (Oct 1 - Dec 31)
Q1 2021 (Jan 1 - Mar 31)
Q2 2021 (Apr 1 - Jun 30)
Q3 2021 (July 1 - Sep 30)
Q4 2021 (Oct 1 - Dec 31)
Q1 2019 (Jan 1 - Mar 31)
Q2 2019 (Apr 1 - Jun 30)
Q3 2019 (July 1 - Sep 30)
Q4 2019 (Oct 1 - Dec 31)
Q1 2020 (Jan 1 - Mar 31)
Q2 2020 (Apr 1 - Jun 30)
Q3 2020 (July 1 - Sep 30)
Q4 2020 (Oct 1 - Dec 31)
Q1 2021 (Jan 1 - Mar 31)
Q2 2021 (Apr 1 - Jun 30)
Q3 2021 (July 1 - Sep 30)
Q4 2021 (Oct 1 - Dec 31)
Was your business restricted due to a governmental order? (E.g., temporary closure, hours reduced, capacity limits, any way your business was altered please list)
Was your business considered "essential" and deemed allowed to maintain all operations?
Yes
No
Part 3: PPP and Other Information
Did you take a 1st Draw PPP Loan? (If "Yes" how much?)
*
Yes
No
If "Yes", how much?
Provide the date received of Loan 1
Percentage of Loan used for Payroll:
Did you take a 2nd Draw PPP Loan? (If "Yes" how much?)
*
Yes
No
If "Yes", how much?
Provide the date received of Loan 1
Percentage of Loan used for Payroll:
Part 4: Startup Companies Only
Did your company start after February 15th 2020?
Yes
No
Are total gross receipts for the 3-taxable-year under $1,000,000?
Yes
No
Submit
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