Form 641 PDF Details

The U.S. Small Business Administration (SBA) Counseling Information Form, better recognized as Form 641, plays a pivotal role in connecting small business owners and entrepreneurs with crucial counseling services. Designed as a comprehensive tool, this form facilitates the initiation of a support relationship between clients and the SBA or its Resource Partners by capturing detailed information about the person or business seeking guidance. From basic identification and contact details to more specific inquiries about the nature of counseling sought, the form encompasses a wide range of data points including client demographics, business specifics, and the preferred counseling focus areas. Furthermore, the form serves as a consent document, through which clients agree to cooperate with future SBA surveys and authorize the sharing of their information with assigned counselors, thereby ensuring a tailored support experience. It also sets the groundwork for the confidentiality and integrity of the counseling process by outlining the terms under which services are offered and by explicitly prohibiting personal gain from the counseling relationship by SBA counselors. Additionally, by including sections for counselor use only, the form extends its utility beyond initial contact, helping counselors keep accurate records of the counseling provided, which is essential for continuous improvement of SBA services and fulfilling reporting requirements to Congressional and Executive bodies. Thus, Form 641 is not just a form but a bridge connecting small business owners with the expertise and resources needed to flourish.

QuestionAnswer
Form NameForm 641
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesform 641, sba gov 641 form, sba counseling, 641 sba form

Form Preview Example

U.S. Small Business Administration

Counseling Information Form

1. Name of the Office Providing the Service _______________________________1a. Type of Client: Face to Face

2. City/State of Office Location_________________________

OMB Approval No.:3245-0324 Expiration Date: 10/31/2020

Client Number:

Location Code:

Initials of Data Inputter:

Online Telephone

PART I: Client Request for Counseling

3. Client Name (Name of the person completing the form/representative of the business)

4. Email

 

 

(Last, First, MI)

 

 

 

 

5. Telephone

 

6. Fax

 

 

Primary

Secondary

 

 

 

7. Street Address/PO Box (give business address if currently in business) 8. City

9. State

10. Zip

+4

 

 

11. I request business counseling service from the Small Business Administration (SBA) or an SBA Resource Partner. I agree to cooperate should I be selected to participate in

surveys designed 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 Resource Partners and host organizations, arising from this assistance.

Use of Information: The information in this form is to be provided by individuals and business seeking technical assistance services from the Small Business Administration (SBA) or an SBA Resource Partner. The information is collected to help SBA's continuing improvement of business counseling programs, to ensure effective oversight and management of entrepreneurial development programs and grants, and to meet Congressional and Executive Branch reporting requirements. The form should be submitted at

 

the site of service to the counselor providing the service. Resource Partners will submit information to SBA according to the terms of their notice of award.

 

12. Preferred date & time for appointment

13. Client Signature

Date:

 

Date:

Time:

 

 

 

PART II: Client Intake (to be completed by all Clients)

 

 

 

 

 

 

 

 

 

14. Race (mark one or more)

 

15. Ethnicity

 

16.Gender

 

17. Do you consider

 

American Indian or Alaska Native

 

Hispanic or Latino

Male

 

yourself a person with

 

Asian

 

 

Not Hispanic or

 

Female

 

a disability?

 

 

 

 

 

 

 

 

 

Black or African American

 

Latino

 

 

 

Yes No

 

Native Hawaiian or Other Pacific Islander

 

 

 

 

 

 

 

White

 

 

 

 

 

 

 

 

18. Veteran Status

No military, Reserve, or

Veteran

 

Member of the Reserve

Member of the National Guard

 

 

National Guard service

Service-Disabled Veteran

Active Duty

Spouse of Military Member

19.Referred by? (Mark all that apply)

SBA District

SBDC

Other Client

 

Magazine/Newspaper

Other (specify)

 

 

 

 

Lender

SCORE

Educational Institution

 

Word of Mouth

USEAC

 

 

 

 

Business Owner

WBC

Local Economic Development Official

Television/Radio

Boots to Business

SBA Web site

VBOC

Chamber of Commerce

 

Internet (please indicate website)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

20a. Are you currently in business?

Yes

No (if no, skip to 30)

20b. If yes, are you currently exporting?

Yes

No

If yes to 20b, please go to Appendix A on page 3 to indicate the markets to which your company currently exports (mark all that apply).

21. Name of Business

22. Type of Business (choose primary category)

 

Professional, Scientific & Technical Services

Mining

Manufacturing

Real Estate & Rental & Leasing

Management of Companies & Enterprises

Utilities

Finance & Insurance

Health Care & Social Assistance

Agriculture, Forestry, Fishing & Hunting

Information

Wholesale Trade

Accommodation & Food Services

Administrative & Support

Construction

Public Administration

Arts, Entertainment & Recreation

Waste Management & Remediation Services

Retail Trade

Educational Services

Transportation & Warehousing

Other Services (except Public Administration)

23. Business Ownership – What percentage of

24. Date Business

25. Do you conduct

26a. Are you a home based business

Yes

No

your business is male or female owned?

Started?(MM/YYYY)

business online?

26b. Are you 8(a) certified?

Yes

No

 

__________% Male__________% Female

 

 

 

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

27a. Total No. of Employees

28a. For your most recent full business year, what

29. What is the legal entity of your business?

 

(full & PT)

were your:

Gross Revenues/Sales $

 

 

 

 

Sole Proprietorship

Corporation

LLC

 

 

 

 

 

 

27b. Of total employees, how many are

 

+Profits/-Losses $

 

 

 

 

 

S-Corporation

Partnership

 

 

28b. Amount of your Gross Revenues/Sales

 

 

 

 

 

engaged in the exporting aspect of your

 

 

 

Other (specify) ________________________________

business: (Full & PT)

 

 

related to exporting $

 

 

 

 

 

 

 

 

 

 

30. What is the nature of counseling you are seeking? (Choose primary category)

Start-up Assistance (How do I start a

Human Resources/

Marketing/Sales (promotion, market

Technology/Computers

small business?)

Managing Employees

research, pricing, etc.)

eCommerce (using the

Business Plan

Customer Relations

Government Contracting (including

Internet to do business)

Financing/Capital (such as applying

Business Accounting/

certifications)

Legal Issues (such as,

for a loan, building equity capital)

Budget

Franchising

Should I incorporate?)

Managing a Business

Cash Flow Management

Buy/Sell Business

International Trade

Tax Planning

Describe specific assistance requested in the space provided. _____________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________

SBA Form 641 (10/24/2017)

U.S. Small Business Administration Counseling Information Form

OMB Approval No.: 3245-0324

Expiration Date: 10/31/2020

Client Number:

Location Code:

Initials of Data Inputter:

Funding Source:

Part III: Counselor Record

31. Client Name (please use the same name from original 641 Part 1)

32. Email

 

 

 

 

 

 

 

 

(Last, First, MI)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

33. Telephone

 

 

 

 

34. Fax

 

 

 

 

 

 

 

 

Primary

 

 

Secondary

 

 

 

 

 

 

 

 

 

 

35. Street Address /P.O. Box

 

 

 

36. City

37. State

38. Zip

 

+4

 

 

39a. Is the client currently in business?

Yes

 

No (if no, skip to 44)

 

 

 

 

40. Date Business

 

39b. Is the client currently exporting?

Yes

 

No

 

 

 

 

Started?

 

 

 

If yes, please turn to Appendix A on page 3 to indicate the markets to which your client currently exports (mark all that

 

 

 

 

 

 

 

 

apply).

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

41a. Total No. of Employees: (Full & PT)

 

 

 

42a. As of the most recent full business year, what were the client's annual:

 

 

 

41b. Of total employees, how many are engaged in

 

Gross Revenues/Sales $_____________________ +Profits/-Losses $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

the exporting aspect of client's business?:

 

 

 

42b. As of the most recent full business year, how much of your client's Gross

 

 

 

(Full & PT)

 

 

 

 

 

 

 

 

 

Revenues/Sales were related to exporting? $

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

43. SBA or Resource Partner Service Contributed to the Following: (Mark all that apply)

SBA Loan Amount $

Certifications

 

 

 

 

 

8(a)

Non-SBA Loan Amount $

Hubzones

 

 

 

 

Amount of Equity Capital Received $

 

SDB

 

No. of Government Contracts/Subcontracts

Other (specify state, local, etc)

 

SBA Financial Assistance

Export Express

Export Working Capital Loan Community Advantage Micro loan

 

 

 

 

SBIR

Annual Value of Government Contracts/Subcontracts Received

 

 

Other (SBIR, SBIC, 7(a) 504, etc)

$

 

 

 

 

 

 

 

44. What was the nature of the counseling you provided the client? (choose primary category)

Start-up Assistance (How do I start a

Human Resources/Managing

Marketing/Sales (promotion,

Technology/Computers

small business?)

Employees

market research, pricing, etc.)

eCommerce (using the Internet

Business Plan

Customer Relations

Government Contracting

to do business)

Financing/Capital (such as, applying

Business Accounting/Budget

(including certifications)

Legal Issues (such as, Should I

for a loan, building equity capital)

Cash Flow Management

Franchising

incorporate?)

Managing a Business

Tax Planning

Buy/Sell Business

International Trade

Please specify other counseling provided.

 

 

 

 

45. Referred Client to (mark all that apply):

WBC

SBA District Office

Export/Import Bank

Dept of Commerce

VBOC

SCORE

USEAC

OPIC

Dept of State

PTAC

SBDC

State Trade Agency

Dept of Agriculture

U.S. Trade & Development Agency

Other

 

 

46.

Type of Session

 

 

47. Language(s) Used

 

48. History

 

 

49. Date Counseled

 

Face to Face

Online

Update

English

Other (specify)

 

New Case

Follow-up

(MM/YYYY)

 

Telephone

Prep

 

Spanish

 

 

 

One Time

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

50.

Counselor(s) Name (If multiple counselors,

list lead counselor first and separate

 

51. Contact Hours

51b. Prep Hours

each additional counselor name by a semi-colon):

 

 

 

Total contact hours

Total amount of

 

 

 

 

 

 

 

 

that a client received

preparation spent by all

 

 

 

 

 

 

 

 

 

 

counselors for a client

51c.Travel Hours Total amount of time it takes to travel to a client's location for counseling

52Did more than one Counselor participate in this counseling session? Yes__ No__. If yes, how many counselors ________?

53.Counselor’s Notes:

SBA Form 641 (10/24/2017)

2

U.S. Small Business Administration

Counseling Information Form

OMB Approval No.:3245-0324 Expiration Date: 10/31/2020

Client Number:

Location Code:

Initials of Data Inputter:

Appendix A to Questions 20b. & 39b.

If your company is currently exporting, please indicate the countries to which your company exports: (Mark all that apply)

ASIA

AFRICA

CARIBBEAN

CENTRAL AMERICA

NORTH AMERICA

Afghanistan

Algeria

Bahrain

Angola

Bangladesh

Benin

Belarus

Botswana

Bhutan

Burkina Faso

Brunei

Burundi

Burma

Cameroon

Cambodia

Cape Verde

China

Central African Republic

East Timor

Chad

Georgia

Comoros

Hong Kong

Congo

India

Democratic Republic of Congo

Indonesia

Cote d'Ivoire

Iran

Djibouti

Iraq

Egypt

Israel

Equatorial Guinea

Japan

Eritrea

Jordan

Ethiopia

Kazakhstan

Gabon

Korea, North

Gambia

Korea, South

Ghana

Kuwait

Guinea

Kyrgyzstan

Guinea-Bissau

Laos

Kenya

Lebanon

Lesotho

Macau

Liberia

Malaysia

Libya

Maldives

Madagascar

Micronesia

Malawi

Mongolia

Mali

Nepal

Mauritania

Oman

Mauritius

Pakistan

Morocco

Philippines

Mozambique

Qatar

Namibia

Russia

Niger

Saudi Arabia

Nigeria

Singapore

Rwanda

Sri Lanka

Sao Tome and Principe

Syria

Senegal

Tajikistan

Seychelles

Taiwan

Sierra Leone

Thailand

Somalia

Turkey

South Africa

Turkmenistan

Sudan

United Arab Emirates

Swaziland

Uzbekistan

Tanzania

Vietnam

Togo

Yemen

Tunisia

 

Uganda

 

Zambia

 

Zimbabwe

Anguilla

Antigua & Barbuda

Aruba

Bahamas

Barbados

Virgin Islands (British)

Cayman Islands

Cuba

Dominica

Dominican Republic

Grenada

Haiti

Jamaica

Montserrat

Netherlands Antilles

St. Kitts and Nevis

St. Lucia

St. Vincent and Grenadines

Trinidad and Tobago

Belize

Costa Rica

El Salvador

Guatemala

Honduras

Nicaragua

Panama

Europe

Austria

Azerbaijan

Albania

Armenia

Belgium

Bosnia-Herzegovina

Bulgaria

Croatia

Cyprus

Czech Republic

Denmark

Estonia

Finland

France

Germany

Greece

Hungary

Iceland

Ireland

Italy

Latvia

Liechtenstein

Lithuania

Luxembourg

Macedonia

Malta

Moldova

Monaco

Montenegro

Netherlands

Norway

Poland

Portugal

Romania

Serbia

Slovak Republic

Slovenia

Spain

Sweden

Switzerland

Turkey

Ukraine

United Kingdom

Vatican City

Bermuda

Mexico

Canada

South America

Argentina

Bolivia

Brazil

Chile

Colombia

Ecuador

Guyana

Paraguay

Peru

Suriname

Uruguay

Venezuela

Oceania

Australia

New Zealand

Cook Islands

Fiji

Kiribati

Marshall Islands

Nauru

Palau

Papua New Guinea

Samoa

Solomon Islands

Tonga

Tuvalu

Vanuatu

Other

Subcontractor for Exporter

_____________________

Please note: The estimated burden for completing this form is 18 minutes. You are not required to respond to any collection information unless it displays a currently valid OMB

approval number. Comments on the burden should be sent to: U.S. Small Business Administration, 409 3rd Street, SW, Washington, DC 20416, and to: Desk Officer SBA, Office of Management and Budget, New Executive Office Building, Room 10202, Washington, D.C., 20503. OMB Approval (3245-0324). PLEASE DO NOT SEND FORMS TO OMB.

SBA Form 641 (10/24/2017)

3

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This document requires specific info to be typed in, thus you should take the time to enter what is expected:

1. While submitting the 641 form sba, be certain to complete all necessary blank fields in their corresponding part. It will help to expedite the process, making it possible for your details to be handled fast and correctly.

Tips on how to fill out sba 641 form stage 1

2. Soon after the first array of fields is done, go to type in the relevant information in these - Hispanic or Latino Not Hispanic or, Female, yourself a person with a, American Indian or Alaska Native, No military Reserve or National, Veteran Status, Referred by Mark all that apply, Veteran ServiceDisabled Veteran, Member of the Reserve Active Duty, Member of the National Guard, SBA District Lender Business Owner, SBDC SCORE WBC VBOC, Other Client Educational, MagazineNewspaper Word of Mouth, and Other specify USEAC Boots to.

Filling out section 2 of sba 641 form

Lots of people generally make errors while completing SBA District Lender Business Owner in this part. Make sure you double-check whatever you enter here.

3. The third stage is normally straightforward - fill out every one of the blanks in Gross RevenuesSales ProfitsLosses, b Of total employees how many are, b Amount of your Gross, Sole Proprietorship SCorporation, Corporation Partnership, Startup Assistance How do I start a, Human Resources, MarketingSales promotion market, small business, Business Plan FinancingCapital, Managing a Business, Managing Employees, Customer Relations Business, Budget, and Cash Flow Management Tax Planning in order to complete the current step.

Writing section 3 of sba 641 form

4. This part arrives with the following blank fields to type in your information in: US Small Business Administration, OMB Approval No Expiration Date, Client Number Location Code, Funding Source, Part III Counselor Record Client, Last First MI, Telephone, Email, Fax, Primary, Secondary, Street Address PO Box a Is the, City No if no skip to No, State, and Yes.

Stage number 4 in filling in sba 641 form

5. While you come near to the end of the form, there are actually just a few extra things to complete. In particular, NonSBA Loan Amount, Amount of Equity Capital Received, No of Government, a Hubzones SDB, Other specify state local etc, Annual Value of Government, Startup Assistance How do I start a, Human ResourcesManaging, MarketingSales promotion, small business, Business Plan FinancingCapital, Managing a Business, Employees, Customer Relations Business, and market research pricing etc must all be filled out.

Completing segment 5 of sba 641 form

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