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Fuel and Electric Assistance Program Self Employment Declaration

If you have not filed taxes, you are required to submit this completed self-employment declaration along with documentation of your business income. Please note: • You must complete all information and sign and date the bottom of the form. • Along with form, you must present supporting documentation in an orderly fashion. Documents should be organized in date order and, if including deductions, should be clearly labelled. Person Self Employed _________________________________ Start Date __________________ Business Name & Activity ___________________________________________________________ Business Address ___________________________________________________________________ 365 Day Period From _____________________________ To _____________________________ For the period indicated above, please provide the following information: 1. Gross Income (for sales, services, tips)

$_____________________ 2. Minus Cost of Goods Sold (products you resell) - $_____________________ 3. Equals Adjusted Gross Income

= $_____________________ Deductions – list the totals for any business-related expense for the period indicated above that you would like to see deducted. Please note that you must include documentation (most often in the form of receipts) as proof of these expenses in order to have deductions.

4. Advertising $_____________ 12. Postage

$______________

5. Bank Charges $_____________ 13. Rent

$______________

6. Car/Truck $_____________ 14. Supplies

$______________

7. Cleaning $_____________ 15. Taxes

$______________

8. Fuel

$_____________ 16. Travel

$______________

9. Insurance

$_____________ 17. Utilities

$______________ 10. Interest

$_____________ 18. Wages (employees) $______________ 11. Office Expense $_____________ 19. Other

$______________

20. Total Deductions (add lines 4 through 19) = $_____________________ 21. Net Profit

(line 3 minus line 20) = $_____________________ I certify that the above information is complete, accurate, and true to the best of my knowledge. I will provide additional documentation upon request if necessary. If understand that if I have intentionally falsified any of this information, I could be fined and/or imprisoned. _____________________________________ ________________________________________ Printed Name

Title

________________________________________ ____________________________________________ Phone Number

Email Address

________________________________________ ____________________________________________ Signature

Date