NeighborImpact Energy Assistance Self-Employment Worksheet

NeighborImpact Energy Assistance Self-Employment Worksheet
Business income MUST be verified with a business bank statement, receipts, or other documentation.
Name of Business:
Applicant Name:

First NameLast Name

Self-Employment Worksheet

Business income MUST be verified with a business bank statement, receipts, or other documentation.
Please provide a bank statement showing business income from the ENTIRE month prior to the date of your signed application. (example: application signed in October should provide a bank statement showing business income from September 1st to September 30th)
Full month for which you are providing data
Total Business Income
Verified by documents from previous month
Business Expenses

For month listed above
Rent (property and/or equipment)
Supplies
Wages to employees
Maintenance/Repairs
Insurance
Utilities for business
Advertising/Marketing
Fuel
Bank Charges/Fees
Add another business expense?
Describe expense
Expense amount
Add another business expense?
Describe expense
Expense amount
TOTAL BUSINESS EXPENSES (add items above)
NET INCOME (Total Income - Total Expenses)
Please provide a bank statement showing business income from the ENTIRE month prior to the date of your signed application. (example: application signed in October should provide a bank statement showing business income from September 1st to September 30th)
Bank Statement

Showing: Business income from the ENTIRE month prior to the date of your signed application
Cancelof

Certification

I certify that the information stated is true and accurate by signing this form. I am under penalty of criminal prosecution if false information results in assistance for which I am not eligible. The undersigned further understands that providing false information herein constitutes the act of fraud.
Signature
Date

MonthDayYear
Date
Should be Empty:

Self-Employment Worksheet