Verification Form – Small Business Assistance

Volunteer Name*

Volunteer Email*

Eligibility Requirements

Business owners whose current household income is less than $8,500 per month AND who have less than $50,000 in liquid assets (cash, bonds, etc.). If you are not sure if you qualify for free services, please submit your information anyway. We will contact you and work with you to help you access the resources you need.

PART I - PERSONAL INFORMATION

Name*

First Last

Email*

Phone*

Additional Contact Phone Number

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Owner's Race/Ethnicity*

Owner's Gender*

Male
Female
Transgender
Non-binary
Prefer Not to Answer

Age*

Check all that apply:

Military/Veteran
LGBTQ
Experiencing Homelessness
Person with a Disability
Immigrant/Refugee

PART II - BUSINESS INFORMATION

Name of Business*

Business Website

Business Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

General Description of Business*

Corporate Structure of Business*

S Corporation
LLC
Sole Proprietorship
Not-for-Profit
Partnership
Other

If other, please describe

Names of Co-Owners

Number of Employees (Full and Part-Time)*

Total sales last year:*

Total profits last year:*

Total sales year to date:*

Total profits year to date:*

Household liquid assets (cash and cash equivalents):*

PART III - PRIOR LEGAL REPRESENTATION

Have you already consulted another attorney or legal organization for legal assistance? If so, please provide:

Name of contact or legal counsel

Name of organization or law firm

E-mail address of contact or legal counsel

Phone number of contact or legal counsel

Brief description of legal issue/services provided

Brief description of legal issue

PART IV – CURRENT COVID-19 LEGAL ISSUE

Type of Legal Issue(s) (please check all that apply)*

Problems with a contract
Problems with my business lease
Questions about how to access COVID relief, like loans and aid
Questions about my employees' safety, wages, paid leave, and benefits
Questions about my business structure (independent contractor, corporation, LLC, etc.) and possible alternatives
Questions about how new COVID regulations (physical distancing, definition of essential business, etc.) apply to my business
Insurance coverage
Bankruptcy
Other

If other, please describe

Please upload any relevant documents in PDF or JPEG form

Drop files here or

Accepted file types: pdf, jpg, Max. file size: 32 MB, Max. files: 1.

Adverse Parties

Please list all other people, organizations, or companies that may be involved in your legal matter(s). For example, if you need help with a commercial lease, please provide the name of the landlord.

PART V – INFORMATION CONCERNING ELIGIBILITY FOR PRO BONO LEGAL ASSISTANCE

How many adults live in your household?*

How many minor children live in your household?*

What is your current monthly household income? (NOTE: Household income is defined as your income plus the income of individuals who you depend on or who depend on you.)*

What was last year’s total annual household income? (NOTE: Household income is defined as your income plus the income of individuals who you depend on or who depend on you.)*

Please list your sources of income, including employment, investments, and government benefits such as unemployment insurance, SSI, SSD, and public assistance:*

Other factors that should be considered in determining your eligibility for pro bono (free) legal assistance:

PART VI – REFERRAL INFORMATION

How did you learn about our services?*

PROBLEMS WITH A CONTRACT

Do you have a question about an existing contract?

Yes
No

Please briefly describe the contract issue:

Do you have a question about a new contract?

Yes
No

Please describe the initial desired terms, and in a few sentences explain why a new contract will help your business, including how it is related to COVID.

PROBLEMS WITH MY BUSINESS LEASE

Which of the following applies to the owners' business lease situation?

Trouble making rent, need assistance for renegotiation, termination, or breach
Seeking renegotiation/renewal on new terms
Resolving a dispute with the landlord

Please briefly describe the business lease issue:

COVID RELIEF PROGRAMS

Do you have a question about money you received from the federal government due to COVID?

One or more of the following: The Paycheck Protection Program (PPP); Economic Injury Disaster Loans (EIDL) & Emergency Economic Injury Grants.

Yes
No

Please describe the question about the federal government funds:

I need help understanding PPP forgiveness terms and applicability
I need help understanding how funds (EIDL or PPP) may be spent
Other

Please confirm the date of application, the date on which you received funds, and the program(s) through which you received funds.

Do you have a question about COVID-related relief for an existing non-disaster SBA (Small Business Administration) loan?

Yes
No

Please briefly describe the question relating to the non-disaster SBA loan, confirm the date on which the SBA loan was received, when it terminates, and what type of loan it is.

Do you have a question about funds received through a loan program, such as the Los Angeles City’s Business Emergency Microloan program?

Yes
No

Please describe your question:

QUESTIONS ABOUT MY EMPLOYEES' SAFETY, WAGES, PAID LEAVE AND BENEFITS

Which of the following employment issues applies to your employment question?

Wage & hour guidance
Classification guidance
Handbook review
Employee medical privacy for COVID testing
Payroll tax credit for COVID time
Sick time/FMLA usage guidance
Furloughs or terminations
Workers' compensation claims related to COVID
Other

Please briefly describe your employment question:

QUESTIONS ABOUT MY BUSINESS STRUCTURE AND POSSIBLE ALTERNATIVES

Do you already have an existing business structure?

Yes
No

If yes, which of the following apply to your business structure question?

Determining whether current entity structure is appropriate
Understanding a legal aspect/requirement of current entity structure
Question about changing entity structure
Ownership dispute
Termination of business entity
Other

If no, which of the following business structure issues apply to your question?

Selecting and forming an entity structure
Understanding risks of not having a formed entity

Please briefly describe your business structure question:

QUESTIONS ABOUT HOW NEW COVID REGULATIONS APPLY TO MY BUSINESS

Do you have a question about the COVID-related orders in the City or County of Los Angeles (called “Safer at Home”), or the State of California?

Yes
No

Which of the following issues with the order applies to your question?

Determining whether my business is an “essential activity or business” for the purposes of a COVID-related order
Question about whether, as an essential business, my business's Social (Physical) Distancing Protocol is compliant with city, county, and/or State orders
Question about resuming business subject to modifications of the “Safer at Home” order
Question about how an order has been/will be enforced; what the penalties are for non-compliance
Question about how to report non-compliant business
Other

Please briefly describe your question:

INSURANCE COVERAGE

Do you have questions about whether an insurance policy you currently hold covers losses incurred as a result of COVID?

Yes
No

Please briefly describe the terms of insurance policy and the nature of losses incurred:

Do you have a question about whether you should buy additional insurance to cover business losses?

Yes
No

Please describe the nature of the business loss anticipated:

Do you have a question about whether your liability insurance covers you in the event your business is sued for a COVID-related injury?

Yes
No

Please briefly describe the nature and terms of insurance policy and the nature of the existing or prospective COVID-related injury:

Are you trying to recover money from your insurance policy due to COVID-related losses that you believe should be covered under your policy?

Yes
No

Please briefly describe the nature and terms of insurance policy and the nature of the COVID-related injury:

Do you any other issues not covered by the previous questions? If so, please explain below:

BANKRUPTCY

Has your company already declared bankruptcy or begun bankruptcy proceedings?

Yes
No

Which of the following bankruptcy issues applies to you?

Basic education and bankruptcy overview
Questions about my business's debt obligations (secured vs. unsecured debt, has anyone personally guaranteed the debt, etc.)
Questions about whether anyone is currently attempting to collect a debt from my business
Questions about impact of litigation against my company on possible bankruptcy
Questions about whether my company has attempted to restructure its obligations prior to considering bankruptcy (Forbearance agreement with lender, sale of assets, bridge loan, negotiation of termination of lease or burdensome contract)
Questions about Chapter 11
Questions about Chapter 7
Questions about the Small Business Reorganization Act
Other

Please briefly describe your bankruptcy question:

BEFORE SUBMISSION

Recommended next step:

Decline as ineligible
Decline for further pro bono representation because legal question answered during the course of this intake
Recommend for pro bono representation (if yes, in addition to submitting this form please prepare a pro bono placement memo and email to covidintake@bettzedek.org, subject line "CLIENT NAME Placement Memo")

Other important/relevant notes (if applicable):

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