SBA Form 3516
OMB Control No: 3245-0423
Expiration Date: 2/28/25
Community Navigators Pilot Program Client and Program Information Form

I request business counseling service from the Small Business Administration (SBA) or Community Navigator. I agreed to cooperate should I be selected to participate in surveys designated to evaluate SBA services. I permit SBA or its agent the use of my name and address for SBA surveys and information mailings regarding SBA products and services (Yes/No). I understand that any information disclosed will be held in strict confidence. (SBA will not provide your personal information to commercial entities.) I authorize SBA to furnish relevant information to the assigned management counselor(s). I further understand that the counselor(s) agrees not to: 1) recommend goods or services from sources in which he/she has an interest, and 2) accept fees or commissions developing from this counseling relationship. In consideration of the counselor(s) furnishing management or technical assistance, I waive all claims against SBA personnel, and that of its Community Navigator and host organizations, arising from this assistance.

Purpose of Collection: The information in this form is provided by the Community Navigator grantees and individuals and businesses seeking assistance from the grantees. . SBA is collecting this information for purposes of its oversight and management of the Community Navigator Program authorized under Sec. 5004 of the American Rescue Plan Act of 2021, and to ensure program equity and integrity. Information collected will only be published in summary or aggregate form as a means of providing SBA management officials, Congress, the White House and OMB with reports on program activity and participant outcomes. SBA expects to produce annual reports to the White House, OMB and Congress on the impact of the Community Navigator Pilot Program leveraging aggregate data to illustrateprogram objectives and outcomes have been met. Please note, SBA may match Form 3516 information with other data sets for program evaluation purposes. In all cases, SBA will protect individual privacy and confidentiality and only aggregate and summary data would be published. Except where indicated otherwise, collectionof the information is required to comply with the terms of the Community Navigator award and is important to SBA to help assess how well the program is serving different communities and to ensure equitable access to the program. Navigators will submit information to SBA according to the terms of their notice of award.

1. Does the Client agree to the above statement? *
2. Client Signed? *
By checking "yes" above, I acknowledge that I am electronically signing this in-take form for participation in the Community Navigator Pilot Program. Please type your name or if counseling is completing during session fill in Verbal Agreement. Your Signature: *