EARNED INCOME INFORMATION SHEET (Complete only if applicable)
Monthly Gross Amount: ___
Place of Employment: ___
Address/Phone/Contact Person: ___
Wages Received: ☐ Yes ☐ No Frequency: ___
Earnings reported monthly to Social Security by: ___
Does employer also report earnings to Social Security? □ Yes □ No
Does IP have tax exempt status (W4)? ☐ Yes ☐ No
Monthly breakdown of previous 12 months gross earned income:
Month/Year
Amount
Has IP completed the nine-month “Trial Work Period”? ☐ Yes ☐ No
Month/Year
Amount
If the answer to #1 is “yes”, has Social Security reviewed IP’s Substantial Gainful Activity Status? ☐ Yes ☐ No
Is IP at the SGA lever, according to Social Security? ☐ Yes ☐ No