Form Ucb/dua-11 Affirmation Of Self-Employment Page 2

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SELF-EMPLOYMENT AFFIRMATION - CONTINUED
Other individuals in my group whose earnings were reported under my Social Security number and who are also filing for DUA
benefits. The net earnings should be allocated as follows:
FULL NAME_____________________________ SS#_____________________ AGE_____ PERCENT_____
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
__________EARNINGS __________EARNINGS __________EARNINGS
FULL NAME_____________________________ SS#____________________ AGE_____ PERCENT______
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
__________EARNINGS __________EARNINGS __________EARNINGS
FULL NAME_____________________________ SS#_____________________ AGE_____ PERCENT______
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
__________EARNINGS __________EARNINGS __________EARNINGS
FULL NAME_____________________________ SS#_____________________ AGE_____ PERCENT______
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
__________EARNINGS __________EARNINGS __________EARNINGS
FULL NAME_____________________________ SS#_____________________ AGE_____ PERCENT______
RELATIONSHIP________________________
_______QTR
_____QTR
_____QTR
_____QTR
_______WKS
_____WKS
_____WKS
_____WKS
_______EARNINGS
__________EARNINGS __________EARNINGS __________EARNINGS
UCB/DUA-11 (3/12)
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