<p> Economic Impact Survey Illinois Small Business Development Center</p><p>Funded in part through a Illinois Eastern Community Colleges cooperative agreement with SBA </p><p>PART I: CLIENT INFORMATION: 1. Client Name (last, First, MI): 2. Company Name:</p><p>3. Email Address:</p><p>Updated Client Information Only In 3 through 13 3. Telephone: 4. Fax Number: Primary: Secondary: 5. Street Address/P.O. Box: 6. City: 7. State: 8. Zip Code: 9. Zip +4:</p><p>10. Is the client currently 11. Month & Year Business 12. Total No. of 13. As of the most recent counseling date and for the in business: Started: Employees: (full & PT) most recent year, what are the client’s annual: Gross Revenues/Sales $______Yes No +Profits/-Losses $______</p><p>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 </p><p>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: </p><p>The results indicated above can be attributed to the assistance received from the Illinois Small Business Development Center at (insert center name) Client Signature: Date:</p><p>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 </p>