Loss of Income Statement Template: Proof & Documentation Guide

Loss of Income Statement Template

[Your Full Name]

[Street Address]

[City, State/Province, ZIP/Postal Code]

[Phone Number]

[Email Address]

Date of Birth: [MM/DD/YYYY]

1. Case, Claim, or Reference Information

Type of Matter (check or describe):

• Motor vehicle accident (may include DUI-related)

• Workplace injury

• Slip-and-fall / premises incident

• Illness or medical condition

• Other personal injury or legal matter

• Other: [Describe]

Date of Incident or Onset of Condition: [MM/DD/YYYY]

Insurance Company (if applicable): [Name]

Claim Number: [Number]

Attorney / Law Firm (if applicable): [Name]

File / Case Number: [Number]

2. Employment and Income Information (Before Incident)

Current Employment Status (check one):

• Employed full-time

• Employed part-time

• Self-employed

• Independent contractor / freelance

• Unemployed at time of incident

• Other: [Describe]

Employer / Business Name: [Name]

Employer / Business Address: [Address]

City, State/Province, ZIP/Postal Code: [City, State, ZIP]

Job Title / Occupation: [Job Title]

Date Employment Began: [MM/DD/YYYY]

Normal Work Schedule (before incident):

[Example: “Monday–Friday, 9:00 a.m.–5:30 p.m., 40 hours per week”]

Pay Structure (check and complete):

• Hourly – Rate: $[Amount] per hour

• Salary – Gross salary: $[Amount] per [year/month]

• Commission-based – Typical commission structure: [Description]

• Self-employed – Typical weekly/monthly net income: $[Amount]

• Other: [Describe]

Average Gross Earnings Before Incident (choose one or more):

• Average weekly gross income: $[Amount]

• Average monthly gross income: $[Amount]

• Reference period used to calculate average (for example, “last 3 months,” “last 12 months”): [Description]

3. Period of Lost or Reduced Income

Dates and reason for loss of income:

• Start date of income loss: [MM/DD/YYYY]

• End date of income loss (if known): [MM/DD/YYYY or “Ongoing”]

Reason unable to work or earn normal income (check all that apply):

• Physical injury

• Illness or medical condition

• Medical treatment, surgery, or recovery time

• Doctor-imposed work restrictions

• Loss of driver’s license or transportation (for work)

• Reduced hours or duties due to limitations

• Suspension or interruption of business operations

• Other: [Describe]

Brief Explanation:

[In your own words, explain how the incident or condition prevented you from working your normal schedule or earning your usual income.]

4. Work Time Missed

Have you missed work or reduced your hours because of this incident or condition?

• Yes

• No

If Yes, provide details:

Full days missed

From: [MM/DD/YYYY]

To: [MM/DD/YYYY or “Ongoing”]

Approximate total number of full days missed: [Number]

Partial days / reduced hours

Approximate number of days where you left early, arrived late, or worked reduced hours: [Number]

Describe typical reduction (for example, “worked 4 hours instead of 8,” “missed one day per week,” etc.):

[Description]

5. Income Before vs. After Incident (Summary)

You may attach pay stubs or a separate spreadsheet. Use this section for a clear summary.

Typical income before incident

• Average gross income per week: $[Amount]

• Average gross income per month: $[Amount]

Actual income during affected period

• Average gross income per week (during loss period): $[Amount]

• Average gross income per month (during loss period): $[Amount]

Calculated loss

• Approximate total gross income you would have earned during loss period if incident had not occurred: $[Amount]

• Actual gross income received during loss period: $[Amount]

• Approximate total gross loss of income: $[Amount]

Brief Explanation of How You Calculated These Figures:

[Example: “I used my average weekly earnings from the 12 weeks before the incident, multiplied by the number of weeks I could not work, and subtracted what I actually earned.”]

6. Other Payments or Benefits Received

During the period of income loss, did you receive any of the following?

• Paid sick leave

• Paid vacation or holiday pay

• Short-term disability benefits

• Long-term disability benefits

• Workers’ compensation benefits

• Unemployment benefits

• Other benefits or assistance: [Describe]

If Yes, provide details for each:

Type of Benefit: [e.g., sick leave, short-term disability]

Provider / Employer / Program: [Name]

Approximate total amount received: $[Amount]

Period covered (dates): From [MM/DD/YYYY] to [MM/DD/YYYY]

Note whether you understand these amounts may be considered when calculating net loss of income for your claim or case.

7. Self-Employment or Variable Income (If Applicable)

If you are self-employed or have variable income (for example, commissions, tips, gig work), briefly describe your business or income source:

Business / Activity Description: [Description]

Normal pre-incident income pattern:

• Average monthly gross revenue: $[Amount]

• Average monthly business expenses: $[Amount]

• Average monthly net income (revenue minus expenses): $[Amount]

Impact of incident on business or income (check and describe):

• Had to cancel or decline jobs or contracts

• Lost clients or customers

• Could not perform services as usual

• Extra costs to hire temporary help or subcontractors

• Other impacts: [Describe]

Brief narrative explaining how your self-employment or variable income was affected:

[Free-text explanation]

8. Supporting Documents

Check all documents you are attaching or can provide on request:

• Pay stubs for several months before the incident

• Pay stubs or records during the loss period

• Tax returns (e.g., last 1–3 years)

• Employer letter confirming job, pay rate, and time missed

• Work schedules or timesheets

• Medical notes or work-status forms (restrictions, off-work orders)

• Benefit statements (disability, workers’ compensation, unemployment)

• Business income records (for self-employed): invoices, bank statements, profit-and-loss summaries

• Other: [Describe]

9. Personal Statement About Income Loss

In your own words, describe how the loss or reduction of income has affected you and your household (optional but often helpful):

[Free-text narrative, for example: impact on bills, rent or mortgage, family support, savings, or daily living.]

10. Declaration and Signature

Read carefully before signing.

I, [Your Full Name], declare that the information provided in this Loss of Income Statement is true, accurate, and complete to the best of my knowledge and belief. I understand that this statement may be used by insurance companies, employers, attorneys, courts, or other parties in connection with my claim or case.

I understand that I am responsible for reviewing this statement and that I may wish to consult a licensed attorney, accountant, or other professional before signing and submitting it.

Signature: _______________________________

Printed Name: [Your Full Name]

Date Signed: [MM/DD/YYYY]

Place Signed (City, State/Province): [Location]

11. Employer Verification Section (Optional, If Requested)

To be completed by employer or HR representative, if applicable.

Employer / Company Name: [Name]

Employer Address: [Address]

City, State/Province, ZIP/Postal Code: [City, State, ZIP]

Employee Name: [Employee’s Full Name]

Employee Job Title: [Job Title]

Employment Start Date: [MM/DD/YYYY]

Current Employment Status: [Active / On leave / Terminated / Other]

Normal Work Schedule (before incident): [Description]

Normal Pay Rate (hourly/salary/commission): [Description]

Verified Dates of Absence or Reduced Hours Related to This Claim:

From: [MM/DD/YYYY]

To: [MM/DD/YYYY or “Ongoing”]

Comments (if any):

[Free-text]

I certify that the information provided in this section is accurate to the best of my knowledge and based on our employment records.

Employer / HR Representative Signature: _______________________________

Printed Name: [Name]

Title / Position: [Title]

Date: [MM/DD/YYYY]