Form Pa 1762 - Mawd Self - Employment Verification Form Page 2
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3RESET FIELDS
MAWD Self – Employment Verification Form
Medical Assistance for Workers with Disabilities
A.
(Required/CAO Completed)
Name __________________________________Record Number or AP Reg Number __________
Address ________________________________________________________________________
PA
-
City __________________________________ STATE ______________ ZIP __________________
Important Information
Your County Assistance Office (CAO) needs information on your self-employment to determine
eligibility for Medicaid coverage and to calculate the monthly premium for MAWD. This information is
Confidential. You have the choice to complete this form or provide other documents that will
verify your self-employment. Please return this form or other documentation that verifies
self-employment to your CAO by ___/___/___. If you need help completing this form or cannot
complete it by this date, call _____________________________ at ____________________.
(CAO Caseworker)
B.
(Required)
Date self-employment started___/___/___. What is your self-employment occupation:
________________________________________________________________________________
________________________________________________________________________________
Does your business have a name?
Yes (print name) __________________________________
No
C.
(Required, unless you just started a self-employment business. See Section D.)
Total gross monthly income from self-employment.
Provide total gross income. ____/____. $_________.____.
(Mo. of Application)
D.
(Complete if you just started a business and do not have proof of income.)
If you just started a business and have not received any income from your business, check this
box:
. When do you expect income? ___/___/___. Do you have an estimate of what your
monthly income will be?_______________________________. If you just started a business and
cannot verify income, your caseworker will contact you to set up a schedule for verifying income.
E.
(Complete if you file taxes.)
If you file taxes, please complete the following for the last quarter you filed or from last year.
(Enter amount for filing period)
(Enter date for filing period)
Federal:
____________________________________
for _______/_______/_______.
State:
____________________________________
for _______/_______/_______.
Local:
____________________________________
for _______/_______/_______.
Other:
____________________________________
for _______/_______/_______.
You do not have to file taxes to qualify for MAWD, but if you do, this information is needed to determine
eligibility and to calculate your premium. If you do not file taxes, check this box:
I do not file taxes.
PA 1762 9/03
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