Statement Template Of Profit And Loss printable pdf download

STATEMENT OF PROFIT AND LOSS

(v10-14)

(Self-Employment Form)

Applicant/Co-Applicant _____________________________________Calendar Month __________________________

Occupation ______________________________ Business Start-Up Date (mm/dd/yy) ___________________________

Business Name _____________________________________________ Are you licensed by the State? ___ Yes ___ No

Business Address __________________________________________________________________________________

Are you registered with the Secretary of State (Indiana) ___ Yes ___ No Do you have an EIN number? ___ Yes ___ No

Instructions: Use the table below to provide a statement of your profit/loss for the previous calendar month. Please

provide revenue (money collected for the sale of your goods or service). You may consider any expense considered as

such by the Internal Revenue Service (IRS) a legitimate expense for CCDF purposes.

Revenue

Expense

Profit/Loss

TOTAL REVENUE

For the Previous Calendar Month:

Expense:

TOTAL EXPENSES

Profit/Loss (Revenue – Expenses)*

PLEASE NOTE: You must also provide a copy of your IRS tax transcript (requested on IRS form 4506T-EX) for the

previous tax year, unless taxes have not been filed due to Business Start-Up Date.

As a new business (less than 8 weeks), I am requesting _______ hours per week of childcare to support my work activity.

By my signature below, I confirm the information provided is a true and accurate representation of my income. I

understand I may be asked to provide documentation supporting revenue and expenses and agree to provide this

information upon request.

Applicant Signature, ____________________________________________ Date ____________

(If there is a co-applicant working in this business, complete this section.)

As a new business (less than 8 weeks), I am requesting _______ hours per week of childcare to support my work activity.

By my signature below, I confirm the information provided is a true and accurate representation of my income. I

understand I may be asked to provide documentation supporting revenue and expenses and agree to provide this

information upon request.

Co- Applicant Signature, ____________________________________________ Date ____________

Statement Template Of Profit And Loss