Self- Employment Verification Form (Page 6 of 6) in pdf

Self- Employment Verification Form Page 6

STATEMENT OF SELF EMPLOYMENT INCOME

Date: _______________

Self-employment income covers the period From __/__/__ To __/__/__

Number of weeks self-employment income covers: ____

CLIENT IDENTIFICATION

LAST NAME:

FIRST NAME:

MIDDLE NAME:

STREET:

CITY:

STATE:

ZIP CODE:

HOME PHONE NUMBER:

LAST FOUR OF SSN:

DATE OF BIRTH:

AGE:

BUSINESS INFORMATION

BUSINESS NAME:

BUSINESS PHONE NUMBER:

BUSINESS ADDRESS:

(

)

—

Total amount of gross receipts*:

$_______

*Gross Receipts are the income you receive from your business. You should retain

supporting documents which show the amounts and sources of your gross receipts.

Total amount of business expenses*:

$_______

*Business expenses are the costs you incur to carry on your business. Your supporting

documents should show the amounts paid for those business expenses.

Total amount of income*:

$_______

*Income is equal to gross receipts minus business expenses.

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

Self- Employment Verification Form Page 6