NOTE: Complete this form if Applicant and/or Adult Household Members are Self-Employed. Print Extra copies if needed
Department of Housing and Economic Development
Mortgage and Housing Investments (MHI) Division
PROFIT AND LOSS STATEMENT
FOR PERIOD: (Month) ______________ (Year)________ TO (Month) _________________ (Year)_________
Applicant’s Name:
Applicant’s Company Name:
Applicant’s Company Address:
REVENUE:
AMOUNT
SALES
$
OTHER
$
OTHER
$
TOTAL REVENUE (A):
$
OPERATING EXPENSES:
AMOUNT
CONTRACT LABOR
$
EQUIPMENT RENTAL
$
MERCHANT SERVICES
$
TELEPHONE
$
SUPPLIES
$
UTILTIES
$
RENT
$
OTHER
$
OTHER
$
OTHER
$
TOTAL OPERATING EXPENSES (B):
$
GROSS INCOME/LOSS (A minus B)
$
The applicant identified herein has applied for housing assistance under a government-assisted program administered
by this office, and authorizes the release of requested information. The information provided in this statement is for
confidential use of this agency and its funders. Please furnish the information requested and return to:
Palm Beach County, Department of Housing and Economic Development
Mortgage and Housing Investments (MHI) Division
100 Australian Avenue, 5
th
Floor, West Palm Beach, FL 33406
Email: HEDVerify@pbcgov.org
PREPARED BY:
Name:
Title:
Address:
Email Address:
Telephone Number:
Signature:
Date:
Warning: Florida Statute817.03 Making false statement to obtain property or credit.—Any person who shall make or cause to be
made any false statement, in writing, relating to his or her financial condition, assets or liabilities, or relating to the financial condition,
assets or liabilities of any firm or corporation in which such person has a financial interest, or for whom he or she is acting, with a
fraudulent intent of obtaining credit, goods, money or other property, and shall by such false statement obtain credit, goods, money or
other property, shall be guilty of a misdemeanor of the first degree, punishable as provided in s. 775.082 or s. 775.083.
