2. Business*
4. Phone*
5. Email*
7. Contact Person*
9. Answers to the following questions will be used to help gauge the economic impact of the COVID-19 outbreak on the City of Abbeville. Participation in filling out this form is completely voluntary and not required. Please note that the information may be shared with state and federal agencies.
11. Has the COVID-19 outbreak:
13. Forced your business to reduce hours?*

    1. Yes
    2. No
14. 2. Forced you to cut hours for employees? *

    1. Yes
    2. No
16. If so, what is your reduction in hours per week:
17. If so, how many employees? How many overall hours?
19. Resulted in your business laying off employees? *

    1. Yes
    2. No
20. Resulted in decreased sales? *

    1. Yes
    2. No
22. If so, how many?
23. If so, what is the percent loss per week? Actual revenue lost per week?
25. In your own words, please describe the impact of COVID-19 on your business
27. Resulted in your business missing utility payments or other bills? *

    1. Yes
    2. No
29. If possible, can you place an estimated dollar amount which would give the overall impact of the COVID-19 outbreak on your business?
31. Agreement
    By signing below, I understand that the information provided in this form may be shared with other agencies besides the City of Abbeville who are working to develop responses to the COVID-19 outbreak which would alleviate some of the strain on small businesses. I also understand that filling out this form is voluntary and does not guarantee my business relief or aid from the federal, state, or local level.
33. Electronic Signature Agreement

    By checking the "I agree" box below, you agree and acknowledge that 1) your application will not be signed in the sense of a traditional paper document, 2) by signing in this alternate manner, you authorize your electronic signature to be valid and binding upon you to the same force and effect as a handwritten signature, and 3) you may still be required to provide a traditional signature at a later date.

    1. I agree.
35. Electronic Signature
Leave This Blank:


37. 1. Receive an email copy of this form.
38. Email address

    This field is not part of the form submission.

39. Submit Submit and Print

* indicates a required field