Self- Employment Verification Form Page 4
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6SELF-EMPLOYMENT WORK HOURS & INCOME
Parent/Guardian Name:
Self-Employment Work Hours / Income
**The customer who signs the receipts or invoices must be available by phone to verify the information, if needed.
WEEK FIVE:
Dates: ___________ thru __________
WEEK SIX:
Dates: ___________ thru ___________
Monday
Monday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Tuesday
Tuesday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Wednesday
Wednesday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Thursday
from ______ AM/PM to ______ AM/PM $_______
Thursday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Friday
Friday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Saturday
Saturday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Sunday
Sunday
TOTAL NUMBER OF HOURS, WEEK FIVE: ______________
TOTAL NUMBER OF HOURS, WEEK SIX: ______________
TOTAL INCOME EARNED, WEEK FIVE:________________
TOTAL INCOME EARNED, WEEK SIX:________________
TOTAL NUMBER OF CUSTOMERS SERVED:_____________
TOTAL NUMBER OF CUSTOMERS SERVED:_____________
**Name and phone number of customers served this
**Name and phone number of customers served this
week must be on receipts or invoices:
week must be on receipts or invoices:
Expenses
List your business expenses for the most recent six week period. Generally, you may claim any business expense
that is allowed by the Internal Revenue Service (IRS), with the exception that we don’t allow a deduction for
depreciation.
DATE
PAID TO
EXPENSE TYPE
CHECK NO.
AMOUNT PAID
$
MONTHLY TOTAL
The information written on this form is true and accurate to the best of my knowledge. I am aware that
if I have given false information intentionally, I may be subject to prosecution for fraud.
x
X__________________________________________________
_________________________________
Date
Parent/Guardian Signature
Verification of Self Employment- rev. 5/10/2016
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