Black Restaurant Fund Growth Capital Intake Form

Think your business is a good fit for the Black Restaurant Fund? If your business is eligible someone from LISC will be in touch to schedule an introductory phone call with you within the next two weeks.

This form captures preliminary information for a business seeking a Growth Capital Investment. Before proceeding, LISC recommends that respondents read the online FAQ for more information.

Terms and Conditions:

LISC is collecting the information in this questionnaire to determine if and how our programs can be of assistance to you. For business owners with multiple businesses, please answer this questionnaire for one business only. Before proceeding, LISC recommends that respondents read the FAQ associated with the program you are interested in for more information. Please email SIGrowthCapital@lisc.org for questions and troubleshooting.

Eligibility is based on accurate and complete submission of this questionnaire. Current directors, officers, employees and contractors of LISC or other donor companies and such individuals' family members (spouse, parents, children, grandchildren, great-grandchildren, and spouses of children, grandchildren, and great-grandchildren) may not be eligible to participate in the program.

Privacy: Information provided through this intake process is the responsibility of each business owner and remains confidential. Applicants will not hold LISC or LISC’s respective affiliates, and/or their affiliates’ respective members, partners, officers, employees, and agents liable for any losses, damages, costs, or expenses of any kind relating to the use or the adequacy, accuracy, or completeness of any information loaded in the form. For further information please see LISC’s privacy policy.

You will see a confirmation page after successful completion of this form.

I acknowledge I have read and agree to the Terms*

You must agree to the terms in order to be considered for this funding opportunity

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Business Name*

Today's Date

Are you completing this information as the lead business owner?*

Please be ready to provide information for the lead business owner below

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Lead Business Owner Information

Primary Contact First Name*

Primary Contact Middle Name

Primary Contact Last Name*

Primary Contact E-Mail*

this email will be used for all official LISC communications

Secondary Contact E-Mail

What is the best phone number to reach the busines

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Business Permanent Phone Number

Phone

Business Owner's Phone Number

Phone

Do you authorize LISC to contact you at the above*

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Website

Primary Business Social Media Address

e.g. Facebook, Twitter, Instagram

Legal Business Name*

Enter the business name as reported on all Federal forms (taxes, W-9, etc)

Enter Doing Business As (DBA), if applicable.

Primary Business Street Address*

For businesses with multiple locations, enter the address of the highest grossing location

Primary Business City/Town*

Primary Business State / Territory*

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Primary Business Zip Code*

Does the primary business address above serve as the registered legal business address (address used on all Federal forms (taxes, W-9, etc))?*

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If not, enter the registered legal business street address

Registered Business City/Town

Registered Business State / Territory

Registered Business Zip Code

Additional Business Information

Structure of Business*

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Other:

Years in Business*

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Select the option that best describes your business location*

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What was your business' gross revenue in the calendar year 2023?*

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What was your business' net profit in calendar year 2023?*

Is your business registered on Uber Eats?*

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Total Number of Workers

The following questions ask about the number of employees at all locations operated by the applicant.

For this section, full-time workers are those who work 35 hours/week or more;

part-time workers are those who work less than 35 hours/week.

To the best of your knowledge, how many full-time workers, including yourself, does your business currently employ at all of it's locations?*

Enter 0 if there are no FT workers

To the best of your knowledge, how many part-time workers, including yourself, does your business currently employ at all of it's locations?*

Enter 0 if there are no PT workers.

Socioeconomic Data

LISC is a nonprofit organization that is generally exempt from taxation under Section 501(c)(3) of the Internal Revenue Code and was formed to further charitable purposes. The below questions seek to determine how your business’ participation in this program furthers LISC’s charitable mission. Providing demographic information is optional, and you are under no obligation whatsoever to provide such information. Your responses will help us be responsive to government and private funders, who are increasingly asking for this information and promote our own accountability to LISC’s goals and mission where we aim to scale proven solutions, seed new ideas for closing racial health, wealth, and opportunity gaps and build the capacity of our partner organizations to do so. If you are comfortable, please respond to the questions below.

The next portion of the survey requests socio-economic data. Please provide information based on how you self-identify.

Age*

Business Owners need to be at least 18 years old

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Gender*

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Veteran*

If yes, you will need to provide DD214 information

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Race/Ethnicity*

(Please specify based on how the lead business owner self-identifies)

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For biracial and multiracial owners, please check all that apply:

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Do you and your business identify as any one of the following (where ownership is based on 51% ownership or more)?

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Explain if and how your race, religion, ethnic origin, gender, sexual orientation, identifiable disability, or other identities have negatively impacted your ability to access capital for your business or grow your business. Describe any examples of such negative impact (e.g., incidents of discrimination or bias you have experienced that have curtailed or limited your business prospects). These examples should come from your individual experience and not describe societal discrimination or bias generally. Clearly describing your experiences attempting to access capital for your business or grow your business is an important part of determining eligibility for this program*

How does your business currently seek to work with or serve socially or economically disadvantaged or underrepresented populations (e.g., hiring or on the job training practices, geographic focus on economically disadvantaged areas, charitable undertakings, etc.)?*

Investment Information

The Growth Capital Program seeks to provide access to flexible, growth-oriented capital to entrepreneurs. These investment dollars are not intended to be used as working capital and are not a replacement for debt financing. Instead, these investments are intended to fully fund a well thought out business expansion/growth plan. Investee businesses will repay LISC if/when their expansion plan succeeds. Please see a full description of the investment terms and structure here. LISC has many other loan and grant programs. Only submit an inquiry for this program if this specific investment type works for your business.

Please specify the primary purpose of these investment dollars*

Include a detailed description or your current business plan and a description of how you would use this investment to expand your business/operations

How much money would you like to request?*

(requests must be for amounts between $50,000 and $250,000)

Please explain exactly what you would spend the above requested dollars on*

Please describe the competitive landscape where you are operating. This will include a description of other businesses that you currently compete with as well as businesses you may be newly competing with given your expansion plan. This should also include an explanation of why you believe you will be successful, given this landscape.

Please outline your most critical suppliers, how they fit into your expansion plan, and any supplier contingency planning you have in place (leave blank if not applicable)

How many jobs do you believe you will add as a result of this business expansion plan? For this section, include any anticipated full or part time hires.

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Are you currently behind with payments related to the business?

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How did you hear about LISC's Growth Capital Program?*

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General comments or any other information about you and/or your business that you would like to share with us.

Final Step: Please Review the Information Below, e-sign and submit

Thank you for completing your intake form. Please click 'Submit' below to complete your submission.

If your business is selected as a finalist, you will be notified via email. Being selected as a finalist does not guarantee an investment will be awarded. As a finalist, additional documentation will be required, including date of birth, SSN, TIN/ITIN and/or EIN for the applicant and/or the business in order for us to perform the due diligence required by the program’s funding source.

This due diligence inquiry may include business verification that we will conduct at our expense. If the due diligence step is successfully completed, we will ask for W-9 and appropriate banking information so that we may transfer funds by ACH to your designated account.

For general questions, please check our website for updates about the LISC Black Restaurant Fund. For additional questions not answered by the FAQ, please email SIGrowthCapital@lisc.org. We are monitoring this email regularly and updating our FAQ accordingly.

For data security questions, please review LISC’s Privacy Policy.

For updates on additional resources and programs, visit LISC's Strategic Investments Website.

By signing your name and submitting the information below, you confirm that the information provided about you and your business are true in all material respects.*

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