Form 4469 is a form used to report any theft or loss of firearms. This form is required to be filed by the person who owns the firearms, and must be filed within days of the theft or loss. The information on this form can help law enforcement track down stolen firearms and bring those responsible to justice. Filing a Form 4469 may also help you recover your firearms if they are ever recovered by law enforcement.
| Question | Answer |
|---|---|
| Form Name | Doh 4469 Form |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | month 17c form, doh deductible applicants get, month i 17c pdf, how to doh 4469 |
NEW YORK STATE DEPARTMENT OF HEALTH Bureau of Medicaid and Family Health Plus Enrollment
Financial Status (Farm or Business)
TO BE COMPLETED BY APPLICANT
APPLICANT’S NAME (First) |
(M.I.) |
(Last) |
BUSINESS NAME |
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APPLICANT’S ADDRESS |
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BUSINESS ADDRESS |
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APPLICANT’S TELEPHONE NO. ( |
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BUSINESS TELEPHONE NO. ( ) |
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Note: Depreciation*, personal expenses and entertainment, personal transportation, purchase of capital equipment and payments of the principals on loans are NOT allowable deductions. Losses from previous years are also NOT deductible. (*Allowed for
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MONTH ONE |
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MONTH TWO |
MONTH THREE |
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I. BUSINESS INCOME |
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________ / ________ |
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(last three months) |
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1. |
Gross Sales |
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2. |
Inventory Purchases |
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3. |
Gross Income (line 1 minus line 2) |
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II. BUSINESS EXPENSES |
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DEDUCTIONS |
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DEDUCTIONS |
DEDUCTIONS |
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4. |
Telephone |
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$ |
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$ |
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5. |
Supplies |
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6. |
Heat/Utilities |
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7. |
Advertising |
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8. |
Interest |
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9. |
Insurance |
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10. Bank Charges |
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11. Repairs |
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12. Business Taxes |
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13. Business Vehicle Expenses |
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14. Business Rent |
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A. Property |
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B. Equipment |
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15. Other Expenses (Specify) |
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III. INCOME SUMMARY |
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SUMMARY |
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SUMMARY |
SUMMARY |
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16. Total Business Expenses |
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(lines 4 thru 15) |
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17. NET INCOME |
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17a |
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17b |
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17c |
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(Line 3 minus line 16) |
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TO BE COMPLETED BY LOCAL DEPARTMENT OF SOCIAL SERVICES WORKER |
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(line 17a + line 17b + line 17c) |
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(line 18 divided by 3) |
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MONTH ONE (17a) |
$______________________ |
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MONTH TWO (17b) |
$______________________ |
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(line 18) |
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3 |
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MONTH THREE (17c) |
$______________________ |
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AVERAGE |
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18. THREE MONTH TOTAL |
$______________________ |
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Applicants must read the following and sign below
I certify that I have no other way to document the above
Applicant’s Signature
Date Signed
Worker’s Signature
Date Signed