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Loss of Income Statement Template
Clearly document your lost wages, reduced hours, and income changes in a structured statement.
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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]
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Loss of Income Statement Template
LOSS OF INCOME STATEMENT TEMPLATE FAQ
What is a Loss of Income Statement?
A Loss of Income Statement is a written document where you explain how an accident, injury, illness, or other event has reduced your earnings. It usually describes your job, normal income before the incident, dates you missed work or had reduced hours, and the financial impact on you or your household. It may be used in insurance claims, personal injury or DUI-related cases, or employment matters.
When is a Loss of Income Statement used?
This statement is commonly used when you are asking an insurance company, court, or other party to compensate you for lost wages or reduced earnings. It is often requested in car accident claims (including DUI-related crashes), workplace incidents, slip-and-fall cases, disability or illness claims, and sometimes in family or financial cases where your ability to earn has changed.
What should I include in a Loss of Income Statement?
A helpful Loss of Income Statement usually includes: your personal and employment details, the type of incident or condition that affected your work, the dates you could not work or had reduced hours, your normal pay before the incident, actual income received during the affected period, and the difference between them. It may also mention other benefits received (such as sick pay or disability payments) and list supporting documents like pay stubs or employer letters.
Who completes a Loss of Income Statement?
The statement is typically completed by the person who lost the income (the claimant). In many cases, insurers, lawyers, or courts will also request a separate employer verification form or letter confirming your job, pay rate, schedule, and time missed. Your own statement and your employer’s documentation usually work together to show the full picture of your income loss.
What documents should I attach to support my loss of income claim?
It is usually helpful to attach recent pay stubs from before the incident, pay stubs or records from after the incident, tax returns (if requested), a letter from your employer confirming time missed and your pay rate, work schedules, doctor’s notes or work-status forms, and any benefit statements (such as disability or sick-pay records). These documents help others verify the figures you list in your statement.
Can AI Lawyer help me write a Loss of Income Statement?
Yes. AI Lawyer can help you organize your dates, pay information, and work history into a clear Loss of Income Statement using this template. You provide the real numbers and documents, and AI Lawyer helps with wording and structure. This is not legal, tax, or financial advice, and it does not replace speaking with a licensed attorney or accountant about your rights, options, or the value of your claim.
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