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Vision Source

COMPLETELY FILLING OUT THIS FORM AND PROVIDING ALL REQUESTED INFORMATION WILL ENSURE A SPEEDY REVIEW OF YOUR REQUEST

Dear Vision Source Member,
We are here to help you. Simply complete the information below. As soon as you submit your request, we will review and respond within 48-72 hours.

ASSESSMENT FORM

* Indicates required field

Your Business Name *

COntact Name *

First

Last

Your Business Address *

Line 1

Line 2

City

State

Zip Code

Country

Your Phone Number *

Your Email *

Person you speak to at the Landlord's office *

Landlord Address *

Line 1

Line 2

City

State

Zip Code

Country

Have you spoken to your landlord? *

Yes No

Are you current on your rent? *

Yes No

If no, when was the last time you paid rent? *

Do you personally guaruntee your lease? *

Yes No

Have you closed your business? *

Yes No

If yes, date you closed? *

If you have reduced your hours, was it due to government order?Choose One *

Yes No

Please describe: *

Landlord's Name (find it on your lease) *

Landlord Phone Number *

Landlord Email *

What is your annual rent? (total and per square foot) *

When does your lease expire? *

Do you have options to extend your lease? *

Yes No

Do you have business interruption insurance in place? *

Yes No

If yes, have you spoken to your agent about your coverage? *

Yes No

If you are still open, have your sales decreased? *

yes no

By how much (%)? *

How many employees do you have? *

Have you laid them off? *

Yes No

What is your monthly net income before you pay yourself? *

How long can you pay rent with your office closed? *

Submit

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