Small Business Development Program Intake Form

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.

We regret that we are unable to assist not-for-profit businesses.

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:*

2021 sales year to date:*

2021 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

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

Max. file size: 1 GB.

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?*

Mayor’s Office/LA Represents
Department of Consumer and Business Affairs (DCBA)

Bet Tzedek may request additional information and documentation to determine eligibility for free legal services, including but not limited to tax returns and a business plan. APPLICANT STATEMENT AND AUTHORIZATION By clicking the submit button below, I acknowledge that I am applying to Bet Tzedek Legal Services for help finding pro bono legal (volunteer) assistance. I understand that Bet Tzedek itself cannot provide me with legal representation or advice, and that Bet Tzedek is collecting information from me and may discuss my case with me solely for the purposes of (1) determining my eligibility for pro bono legal assistance; (2) assessing whether, in Bet Tzedek's discretion, the legal matter(s) I present are appropriate for pro bono legal assistance; and (3) attempting to find pro bono legal assistance for me. I also understand that: · Bet Tzedek may not be able to find pro bono legal assistance for me, and there is no assurance that Bet Tzedek or the law firms participating in Bet Tzedek's Small Business Development Project will be able to advise or represent me. · Bet Tzedek cannot respond to crises, and cannot guarantee the length of time it may take to find a volunteer attorney, or to determine that pro bono legal assistance is not available or that the legal matter(s) presented are not appropriate for pro bono legal assistance. I further acknowledge that Bet Tzedek may share the information I provide in this application, including information I provide in my discussions with Bet Tzedek's staff and in any other documents or records I provide to Bet Tzedek, with law firm staff and/or with volunteer attorneys. Bet Tzedek will share this information solely for the purpose of enabling law firm staff and/or volunteer attorneys to consider whether to represent me pro bono. While legal assistance provided to me by Bet Tzedek and Bet Tzedek’s volunteers and partner organizations is free, I am responsible for other expenses related to this matter, which may include, but are not limited to, fees associated with government or regulatory filings, costs related to government publication requirements, and charges for services provided by third-party service providers. I am providing an Intake Form to support my application. I understand that Bet Tzedek, volunteer attorneys, and law firms participating in Bet Tzedek's Small Business Development Project are relying on the accuracy of the Intake Form and all of the information I provide. I affirm that all of the information I am providing in the Intake Form is true and correct.

Small Business Legal Resources for COVID Questions

Small Business COVID-19 Assistance Application

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