1
2
3Monthly Business Income and Expense Report
Name: _________________________________________________________ Case Number: _____________________
Address: ________________________________________________________ Postal Code: ______________________
Name of business: _______________________________________________ Type: ____________________________
Report for the month of ______________________ /______
Income
Sales, Gross Revenue
Less: Returns and Allowances
Less: Provincial Sales Tax (if included in sales)
Add: Other Income - specify (include cash draw)
Gross Income
=
Cost of Goods Sold
Value of inventory at beginning of month
Add: Purchased (
)
including delivery, express, freight
Less: Value of inventory at end of month (
)
total from page 2
Less: Cost of items withdrawn for purposes such as demonstration
Cost of Goods Sold (
)
=
deduct from Gross Income
Gross Profit (Gross Income less Cost of Goods Sold)
(If above is zero or
less, go to page 2)
Business Expenses
- Please submit receipts
Accounting, Legal, Collection, Consulting
Business vehicle (
)
maintain any leasing/rental agreement in force at time of application
Mortgage interest or business holdings in existence at time of application
Delivery, express, freight
Office expenses (
)
postage, stationery, etc.
Rental on business property
Minor equipment costs/rental for essential business operations
Fuel/maintenance/repairs for business vehicles
Wages
Contributions to employees (
)
C.P.P., E.I., Workers’ Compensation
Business property tax
Licenses
Insurance
Utilities
Advertising (
)
Newspaper, Business pages, telephone directories, etc.
Mileage, Meals, and Accommodation for business trips
Goods and Services Tax
Other - specify
Total Expenses
=
Net Income (Gross Income less Total Expenses)
saskatchewan.ca
| Page 1 of 3 | 1214 Rev. 12/12
Monthly Business Income and Expense Report
Name: _________________________________________________________ Case Number: _____________________
Address: ________________________________________________________ Postal Code: ______________________
Name of business: _______________________________________________ Type: ____________________________
Report for the month of ______________________ /______
Income
Sales, Gross Revenue
Less: Returns and Allowances
Less: Provincial Sales Tax (if included in sales)
Add: Other Income - specify (include cash draw)
Gross Income
=
Cost of Goods Sold
Value of inventory at beginning of month
Add: Purchased (
)
including delivery, express, freight
Less: Value of inventory at end of month (
)
total from page 2
Less: Cost of items withdrawn for purposes such as demonstration
Cost of Goods Sold (
)
=
deduct from Gross Income
Gross Profit (Gross Income less Cost of Goods Sold)
(If above is zero or
less, go to page 2)
Business Expenses
- Please submit receipts
Accounting, Legal, Collection, Consulting
Business vehicle (
)
maintain any leasing/rental agreement in force at time of application
Mortgage interest or business holdings in existence at time of application
Delivery, express, freight
Office expenses (
)
postage, stationery, etc.
Rental on business property
Minor equipment costs/rental for essential business operations
Fuel/maintenance/repairs for business vehicles
Wages
Contributions to employees (
)
C.P.P., E.I., Workers’ Compensation
Business property tax
Licenses
Insurance
Utilities
Advertising (
)
Newspaper, Business pages, telephone directories, etc.
Mileage, Meals, and Accommodation for business trips
Goods and Services Tax
Other - specify
Total Expenses
=
Net Income (Gross Income less Total Expenses)
saskatchewan.ca
| Page 1 of 3 | 1214 Rev. 12/12
Inventory
Wholesale
Description
Quantity
Value
Retail Value
Value
Total
saskatchewan.ca
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I state that the information given in this Monthly Business Income and Expense Report, is true, correct and that I
have not withheld any information which may have an effect on my social assistance benefits. I understand I may
be liable to criminal prosecution for withholding information or providing false or misleading information.
My Rights and Responsibilities
I have the right to the protection of my personal information pursuant to The Freedom of Information and Protection of
Privacy Act and The Health Information Protection Act. I have the right to access my personal information in the possession or
control of the ministry.
I understand that the information provided in this application will be retained and disposed of in accordance with The
Archives Act of the Province of Saskatchewan.
I am aware that I may appeal the assessment of my eligibility or the calculation of my benefits.
I agree to report to the Ministry of Social Services any changes in my circumstances, or the circumstances of my family
members, that effect my eligibility for assistance or the eligibility of my family members. I understand some examples of
such changes include changes include changes in address, receipt or expected receipt of money, goods or other assets from
any source, needs, number of family members, and marital status including common-law relationships. If I am in doubt as to
whether any change in circumstances will affect my eligibility, I agree to report this to the Ministry of Social Services.
I, as applicant, understand that any payments I receive for which I am not entitled, will be deducted from future payments.
I understand that excess payments result from a failure to report changes. I understand I am also responsible for re-paying
excess payments which result from my spouse’s failure to report changes.
I must make every effort to be self supporting. I understand this includes pursuing employment and child support,
participating in training or attending educational programs or obtaining income from other sources.
Client Consent
I give consent to the Ministry of Social Services to obtain and verify information or documents required to confirm my
eligibility, or the eligibility of family members for social assistance. I understand such information includes needs, money
received from any source, assets, marital status (including common-law relationships), and living arrangements of myself or
family members.
I give consent to any person having such information or documents to release them upon written or verbal request to
employees of the Ministry of Social Services. I understand examples include, but are not restricted to, information or
documents from: Human Resources and Skills Development Canada (Employment Insurance), Workers’ Compensation
Board, Saskatchewan Government Insurance, any bank, credit union or other financial institution, any landlord, and past
employers. I give consent to use my Social Insurance Number and the Health Services Number of myself and my family
members for purposes of determining our eligibility or benefits.
I give consent to the Ministry of Social Services to disclose my/our information to third parties where the information is
necessary to verify and confirm my eligibility for benefits or to assist in providing additional benefits. I understand third
party examples include, but are not restricted to, Canada Revenue agency, The Ministry of Education, the Ministry of
Economy, Workers’ Compensation Board, Canada Pension Plan, Sask Power, Sask Energy, Indian Bands, Public Trustee and
other provincial social assistance programs. I give consent to disclose and use my information for evaluation and research to
improve programs and services.
I authorize Canada Revenue Agency to release to the Ministry of Social Services any information from my income tax returns
and other taxpayer information. The information will be relevant to, and will be used solely for the purpose of determining
and verifying eligibility for, and the general administration and enforcement of the social assistance program under
The Saskatchewan Assistance Act. This authorization is valid for the taxation year prior to the year of signature and each
subsequent consecutive taxation year for which benefits are requested.
________________________________________________
_________________________________________________
Signature of Client
Signature of Spouse (if present)
________________________________________________
_________________________________________________
Signature of Trustee/Receiver
Witness (if signed by mark)
_____________________________________
Year/Month/Day
saskatchewan.ca
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