AJFC Community Action Agency

30-Day Gig / Self-Employment Income Tracking Form

Record income from gig work, temporary work, cash jobs, self-employment, or small business activity.

Instructions: Enter your information and tracking start date. Record each day's work, gross income, work-related expenses, and whether you have supporting proof. Dates and totals calculate automatically. Enter 0 for days with no income. Keep receipts, invoices, payment screenshots, bank deposits, cash logs, pay-app records, contracts, or customer statements.

Privacy: This tool does not store or send your entries. Print or save your completed form before leaving or refreshing this page. Do not enter Social Security or account numbers. Entering an email address does not email the form.

Client Information

Full name Email address Phone number County Mailing address City, state, ZIP Tracking period start date Tracking period end date

Daily Income Log

Gross = income before expenses. Expenses = costs related to the work. Net = gross minus expenses. On small screens, swipe across the table.

Day	Date	Type of Work / Customer	Gross $	Expenses $	Net $	Proof?

Total Gross Income $0.00

Total Expenses $0.00

Total Net Income $0.00

Notes about income, expenses, or supporting documents

Client Certification

I certify that the income listed is true and complete to the best of my knowledge. I understand that proof of income is required.

Client typed name Certification date

AJFC may require a handwritten signature on the printed form.

AJFC Staff Use Only

Proof attached / reviewed Staff name Staff signature Review date

Provide the completed form and supporting documents to AJFC through its approved submission process. Completing this form does not submit an application or guarantee assistance.