Form Cmsp 1178 County Medical Services Program Profit And Loss Statement printable pdf download

COUNTY MEDICAL SERVICES PROGRAM

PROFIT AND LOSS STATEMENT

Beneficiary name

Social security number

For the month ending (month, year)

Business name

Type of business

(See reverse for instructions for completion.)

PART I

Complete this section if you buy and then resell a product or if you make a product for

COUNTY USE ONLY

sale. Otherwise, start with Part II.

1. Cost of products on hand at beginning of month ............................................

$ ____________

2. Cost of products you purchased during month ..................... + $ ____________

3. Cost of materials and supplies used to make products ........ + $ ____________

4. Other costs to make products ............................................... + $ ____________

5. Total costs of products or supplies purchased during month.......................... + $ ____________

6. Total of products on hand at beginning of month plus cost of

products or supplies purchased during month (line 1 plus line 5)................... = $ ____________

7. Cost of total products on hand at end of month .............................................. - $ ____________

8. Cost of products sold during month (line 6 minus line 7) ................................ = $ ____________

PART II—INCOME

1. Gross receipts or sales....................................................................................

$ ____________

2. Cost of products sold (Enter amount from Part I, number 8; if you did not

sell a product, enter zero here.) ...................................................................... - $ ____________

3. Adjusted gross income .................................................................................... = $ ____________

PART III—DEDUCTIONS FOR OPERATING COSTS

1. Advertising......................................................

$ ____________

23. Windfall profit tax withheld

$ ____________

2. Bad debts from sales or service .....................

$ ____________

3. Bank service charges .....................................

$ ____________

24. Other expenses (specify):

4. Car and truck charges ....................................

$ ____________

5. Commissions ..................................................

$ ____________

a. ___________________

$ ____________

6. Depletion ........................................................

$ ____________

7. Depreciation ...................................................

$ ____________

b. ___________________

$ ____________

8. Dues and publications ....................................

$ ____________

9. Employee benefit programs ...........................

$ ____________

c. ___________________

$ ____________

10. Freight (not included in Part 1 above) ............

$ ____________

11. Insurance........................................................

$ ____________

d. ___________________

$ ____________

12. Interest on business indebtedness.................

$ ____________

13. Laundry and cleaning .....................................

$ ____________

e. ___________________

$ ____________

14. Legal and professional services .....................

$ ____________

15. Office expense ...............................................

$ ____________

f. ___________________

$ ____________

16. Rent on business property .............................

$ ____________

17. Repairs ...........................................................

$ ____________

g. ___________________

$ ____________

18. Supplies (not included in Part 1 above) .........

$ ____________

19. Taxes (Do not include windfall profit tax.) ......

$ ____________

h. ___________________

$ ____________

20. Travel and entertainment ...............................

$ ____________

21. Utilities and telephone ....................................

$ ____________

i. ___________________

$ ____________

22. Wages ............................................................

$ ____________

25. Add amounts in columns for lines 1 through 24 (Part III). These are the total deductions: .................. $ _______________

PART IV—NET PROFIT OR LOSS (line 3, Part II, minus line 25, Part III).................................................... $ _______________

I declare under penalty of perjury that the foregoing statements are true and correct.

Beneficiary signature

Date

Page 1 of 2

CMSP 1178 (10/05)

Form Cmsp 1178 County Medical Services Program Profit And Loss Statement

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