SBA Form 3516
OMB Control No: 3245-0423
Expiration Date: 12/31/21 (Copy)
Community Navigators Pilot Program Client and Program Information Form

Use of Information Collected: Information collected from SBA Form 3516 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 illustrate program 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.

Privacy Act Statement (5 U.S.C. 552a)

The information in this form is provided by individuals and businesses seeking assistance from a Community Navigator. The information is collected to help SBA’s oversight and management of the Community Navigator Program, ensure program equity and integrity and to meet Congressional and Executive Branch reporting requirements.  Some of the information collected is voluntary however it is important to SBA to help assess how well the program is serving different communities and to ensure equitable treatment of all people. Only you, the Community Navigator from which you are seeking assistance and SBA will be privy to the individualized confidential and proprietary information.  Any personal information collected, including the client’s Social Security Number, will be protected to the extent permitted by law, including the Privacy Act of 1974 and the Freedom of Information Act.   SBA has instituted procedures to protect confidentiality and only aggregate and summary data will be provided in public reports to the Congress and the White House.

Client Confidentiality Statement (Please read following)
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.
1. Does the Client agree to the above statement? *
2. Client Signed? *
Your Signature: *