HTML Preview Self Employment Profit And Loss Statement Form page number 1.
STATEMENT OF PROFIT AND LOSS (v2-16)
(Self-Employment Form)
Applicant/Co-Applicant _____________________________________ Previous 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:
Expense:
Expense:
Expense:
Expense:
Expense:
Expense:
Expense:
Expense:
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 your
most recently completed 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 ____________