Form Cmsp 1178 County Medical Services Program Profit And Loss Statement Page 2
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1
2INSTRUCTIONS FOR COMPLETION
1. In order to complete Part 1, you must make a list of all the stock you had on hand at the beginning of the month and how much it cost
you, either to purchase it from your supplier or to make it, if you are making a product for resale. You can use an inventory control form
similar to the example shown below so this information will be easily available to you each month.
Example:
Type of
Cost
Number of
Sold Month
Sold
Product
per Item
Purchases
of May 1999
Balance
Month of
Balance
Rings
$2.00
100
20
80
Bracelets
$5.00
100
10
90
Necklaces
$8.00
100
10
90
2. If you had other types of business expenses such as the examples listed below, list them under Part III, Items 1 through 24i.
A. Wages for employees
B. Business insurance
C. Advertising costs
D. Federal, state, or county/city taxes paid
E. Maintenance and repairs of business equipment
F. Commissions paid to others
G. Business organization dues
H. Subscriptions to business publications
I.
Employee benefits (Social Security paid, state disability, pension funds)
J. Freight to ship products purchased or sold
K. Interest on business loans (Principal payments are not allowed.)
L. Laundry and cleaning
M. Legal and professional services
N. Travel expenses
O. Union dues
P. Business licenses
3. The following are not allowable business expenses:
A. Personal expenses such as income tax payments, lunches, and transportation to and from work
B. Purchase of equipment
C. Payment on the principal of loans for equipment
4. Attach verification of income and expenses to this statement:
A. Income verification such as copies of sales slips, customer invoices, receipts, or ledgers
B. Expense verifications such as receipts for items purchased, cancelled checks, bills marked paid
5. Privacy and Confidentiality Notification: The Welfare and Institutions Code, Sections 14011 and 14012, authorizes county welfare
departments to collect certain information from you to determine if you or the persons you represent are eligible for the County Medical
Services Program (CMSP). The information you provide is confidential and may only be disclosed to certain individuals or organizations
and then only to administer the CMSP. The information will be used by the county welfare department to establish initial and ongoing
CMSP eligibility; by the State’s fiscal intermediary for claims processing; by the Department of Health Services for CMSP card
production and overpayment recovery actions; for Social Security account number verification; and by medical providers of services and
health maintenance organizations for eligibility certification.
Providing this information is mandatory. Failure to do so will result in your ineligibility for CMSP benefits. You have the right to look at
your information and may do so at the county welfare office during regularly scheduled office hours.
Page 2 of 2
CMSP 1178 (10/05)
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