Sample data collection form

Federal law requires that we request the following information to help ensure that all small businesses applying for loans and other kinds of credit are treated fairly and that communities' small business credit needs are met.

One or more employees or officers involved in making a determination concerning your application may have access to the information provided on this form.

  • However, FEDERAL LAW PROHIBITS DISCRIMINATION on the basis of your answers on this form.
  • Additionally, we cannot discriminate on the basis of whether you provide this information.
  • While you are not required to provide this information, we encourage you to do so.
  • Importantly, our staff are not permitted to discourage you in any way from responding to these questions.

Filling out this form will help to ensure that ALL small business owners are treated fairly.

Business ownership status

Please indicate the business ownership status of your small business. For the purposes of this form, your business is a minority-owned, women-owned, or LGBTQI+-owned business if one or more minorities,* women, or LGBTQI+ individuals (i) directly or indirectly own or control more than 50 percent of the business AND (ii) receive more than 50 percent of the net profits/losses of the business.

What is your business ownership status?
(Check one or more of the options below)

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*Minority means Hispanic or Latino, American Indian or Alaska Native, Asian, Black or African American, or Native Hawaiian or Other Pacific Islander. A multi-racial or multi-ethnic individual is a minority for this purpose.

Number of principal owners

For the purposes of this form, a principal owner is any individual who owns 25 percent or more of the equity interest of a business. A business might not have any principal owners if, for example, it is not directly owned by any individuals (i.e., if it is not owned by another entity or entities) or if no individual directly owns at least 25 percent of the business.