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

For SSDI Recipients:

1. Has IP completed the nine-month “Trial Work Period”? ☐ Yes ☐ No
2. Month/Year
3. Amount
2. If the answer to #1 is “yes”, has Social Security reviewed IP’s Substantial Gainful Activity Status? ☐ Yes ☐ No
3. Is IP at the SGA lever, according to Social Security? ☐ Yes ☐ No