Page 4 of 6
Business Income Information
Enter the average gross monthly income of your business. To determine your gross monthly income use the most recent 6-12 months documentation
of commissions, invoices, gross receipts from sales/services, etc.; most recent 6-12 months earnings statements, etc., from every other source of
income (such as rental income, interest and dividends, or subsidies); or you may use a most recent 6-12 months Profit and Loss (P&L) to provide the
information of income and expenses.
Note: If you provide a current profit and loss statement for the information below, enter the total gross monthly income in Box 2 below. Do
not complete lines (6) - (10).
Gross rental income
Other income (Specify on attachment)
Box 2 Total Business Income
Add lines (6) through (10) and enter the amount in Box 2 =
Business Expense Information
Enter the average gross monthly expenses for your business using your most recent 6-12 months statements, bills, receipts, or other documents
showing monthly recurring expenses.
Note: If you provide a current profit and loss statement for the information below, enter the total monthly expenses in Box 3 below. Do not
complete lines (11) - (20).
Materials purchased (e.g., items directly related to the production of a product or service)
Inventory purchased (e.g., goods bought for resale)
Gross wages and salaries
Supplies (items used to conduct business and used up within one year, e.g., books, office supplies, professional
Vehicle costs (gas, oil, repairs, maintenance)
Insurance (other than life)
Current taxes (e.g., real estate, state, and local income tax, excise franchise, occupational, personal property,
sales and employer's portion of employment taxes, etc.)
Other expenses (e.g., secured debt payments. Specify on attachment. Do not include credit card payments)
Box 3 Total Business Expenses
Add lines (11) through (20) and enter the amount in Box 3 =
Box 4 Remaining Monthly Income
Subtract Box 3 from Box 2 and enter the amount in Box 4 =
If number is less than zero, enter zero.
Catalog Number 55897B