Form Il 444-2790 - State Of Illinois Department Of Human Services Self-Employment Record
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1
2State of Illinois
7 (PERMANENT)
Department of Human Services
SELF-EMPLOYMENT RECORD
Client Name:
Client Number:
Address:
Caseload Number:
This self-employment income is for the period of
through
.
Because you are self-employed, you are required to report all of your employment income and employment expenses to the
Department of Human Services. This information is to be supplied with your EI REDE application. In order to determine your
eligibility for assistance, you must provide us with accurate and complete records of money you take in and the work expenses
you pay out. To do this you must write down all money you take in and its source. You must also write down any expenses you
had in producing your income. Be sure to include all transactions which occurred during your reporting period. Also,
save your receipts.
Expenses of producing income include but are not limited to things like inventory, materials, services, transportation, employee
salaries, and loan payments. You may choose what month you want to claim an expense, but you cannot claim the expense
more than once. You may only claim the percentage of the vehicle costs equal to the percentage of mileage that the vehicle is
used for business purposes. Depreciation, charitable contributions, entertainment, and personal expenses are NOT allowable
business expenses.
If you wish, you may use this form to keep your records. You are not required to complete this form, but you are required to
keep accurate records of your self-employment income and expenses. The Department will need a copy of the record you
choose to use. If you do complete this form, your DHS office will be better able to determine your eligibility for benefits.
Business Income Source
Date
Gross Income Business Expenses
Amount
Received
Expense/ItemPurchased/
Paid to Whom
Page 1 of 2
IL 444-2790 (R-5-04)
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