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ERC Qualification Form

Employee Retention Tax Credit (ERTC)

Do you Qualify?*
Note: All responses will be kept confidential and not shared with any other parties.

Company Name:

Address:

City:

State:

Postal Code:

Email:

Phone:

Contact Name:

Contact Cell Phone or Direct Line:

Greatest number of employees in 2019?

Does your company have branch offices or subsidiaries?

Yes

Please list city and state of your other locations below (up to 6):

Location 1 City:

Location 1 State:

Location 2 City:

Location 2 State:

Location 3 City:

Location 3 State:

Location 4 City:

Location 4 State:

Location 5 City:

Location 5 State:

Location 6 City:

Location 6 State:

Questions:

1. In 2020 did you have a drop in gross receipts of 50% or more compared to 2019?

Yes

2. In 2021 did you have a drop in gross receipts of 20% or more compared to 2019?

Yes

3. Do you have a showroom in any of your business locations where you sell to the public that was closed down for any period of time due to a State or Local mandate?

Yes

4. Does New Construction make up over 10% of your business volume?

Yes

5. Do Maintenance Agreements make up over 10% of your jobs during a year or a given quarter?

Yes

7. Were there any city or local mandates that were issued during 2020 or 2021 that directly affected your operations (branches and subsidiaries included)?

Yes

8. Do you have a special situation where you feel your company was directly impacted by Governmental regulations that you want to discuss?

Yes

If you can answer YES to any of these questions you may be eligible for all or a portion of the Employee Retention Tax Credit (ERTC). The ERTC is not a loan, it is a refundable tax credit of up to $5,000 per employee for 2020 where your company was affected by a governmental mandate, and $21,000 per employee for 2021 if you were affected during that time by a direct governmental mandate.

Note: Even if you received funds under the Payroll Protection Program (PPP) you may still qualify for the ERTC

ERC Qualification Form

Employee Retention Tax Credit (ERTC)

Do you Qualify?* Note: All responses will be kept confidential and not shared with any other parties.

Questions:

Do you Qualify?*
Note: All responses will be kept confidential and not shared with any other parties.