Tax Schedule C Form

TAX SCHEDULE C FORM

Taxpayer Name:   Tax Year:
Social Security Number or EIN:   Business Name (if different):
Preparer Name:   Preparer ID/ PTIN / EIN:

RECITALS

WHEREAS, the Taxpayer conducts or conducted during the Tax Year a sole proprietorship or single-member business activity requiring the reporting of gross receipts, allowable business expenses, and net profit or loss in accordance with applicable tax statutes and administrative rules; and

WHEREAS, the Taxpayer has engaged or acknowledges the preparer to assist in the preparation, assembly and review of the accounts and statements necessary to complete the Schedule C reporting obligations for the stated Tax Year; and

WHEREAS, the information set forth in this Schedule C is intended to be the Taxpayer's sworn statement of profit or loss from business, made under penalty of perjury when signed by the Taxpayer below.

NOW THEREFORE, in consideration of the foregoing recitals, the Taxpayer and Preparers state and enter the following Schedule C reporting information for the referenced Tax Year:

1. BUSINESS INFORMATION

Accounting method: Cash Accrual Other:

2. INCOME

3. EXPENSES

4. COST OF GOODS SOLD

5. NET PROFIT OR LOSS

Gross income (from Section 2) less total expenses (from Section 3) equals:

If a loss, answer the following: was the activity for profit? Yes No

6. OTHER INFORMATION

Did you materially participate in the operation of this business? Yes No

Did you make any payments that would require filing Form(s) for household or contractor wages? Yes No

7. DECLARATION AND CERTIFICATION

I certify under penalties of perjury that the information given on this Schedule C and any accompanying schedules and statements is true, correct and complete to the best of my knowledge and belief. I acknowledge that this Schedule is provided for reporting business income and expenses for the Tax Year identified above and that improper reporting may subject me to assessment, interest and penalties under applicable tax law.

Taxpayer contact phone:   Taxpayer email:

GOVERNING PROVISIONS

Governing Law: This Schedule and the declarations contained herein shall be construed and enforced in accordance with the internal laws of the jurisdiction where the Taxpayer maintains the principal place of business, without regard to conflict of law principles.

Entire Agreement: This Schedule C constitutes the complete written statement of the Taxpayer's report of profit or loss for the stated Tax Year and supersedes all prior oral and written representations specific to the reporting of such income and expenses.

Severability: If any provision of this Schedule is held invalid or unenforceable, the remaining provisions shall continue in full force and effect.

Notices: Any notice required or permitted to be given under this Schedule shall be in writing and delivered to the addresses stated in this form or any subsequent address provided in writing.

Amendments and Waiver: No amendment or waiver of any provision of this Schedule shall be effective unless in writing and signed by the party to be charged.

Counterparts: This Schedule may be executed in counterparts and by electronic or facsimile signature, each of which shall be deemed an original and all of which together shall constitute one instrument.

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