Form Pa 1762 - Mawd Self - Employment Verification Form Page 3
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3MAWD Self – Employment Verification Form
Medical Assistance for Workers with Disabilities
F.
(Complete if you have business expenses and can provide proof of the expenses.)
Certain costs of running a business can be deducted from your total gross monthly/annual income
from self-employment. If you can verify costs, complete the following. Circle if this is a monthly or
yearly amount for the expense.
Accounting and Legal Fees:______________________________________
Monthly/Yearly
Advertising Costs:______________________________________________
Monthly/Yearly
Business Transportation: ________________________________________
Monthly/Yearly
Professional License Fees/Union Dues: ____________________________
Monthly/Yearly
Costs of maintaining a place of business, such as rent, property taxes, insurance, maintenance,
utilities. If you operate your business from your home, only those costs that are identified for the part
of the home that is used for the business can be deducted.
Rent: ________________________________________________________
Monthly/Yearly
Business Property Mortgage: ____________________________________
Monthly/Yearly
Property Taxes:________________________________________________
Monthly/Yearly
Insurance: ____________________________________________________
Monthly/Yearly
Maintenance: ________________________________________________
Monthly/Yearly
Telephone: __________________________________________________
Monthly/Yearly
Utilities: ______________________________________________________
Monthly/Yearly
Other: ______________________________________________________
Monthly/Yearly
Goods purchased, supplies and materials used to operate a business. This may include: paper,
computer, Internet access, copier, fax, etc.
____________________________________________________________
Monthly/Yearly
____________________________________________________________
Monthly/Yearly
____________________________________________________________
Monthly/Yearly
Other Costs: __________________________________________________
Monthly/Yearly
If you do not have verification of costs, check this box:
I do not have verification of costs.
G.
(Required. You must sign this form.)
I certify that, subject to penalties provided by law, the information I gave is true, correct and
complete to the best of my knowledge.
____________________________________
____/____/____
__________________________
Signature
Date
Please Print Name
E-mail address (optional) ____________________________________________________________
If someone helped you complete this form, please have the person complete the following.
Name: ______________________________ Date ___/___/___ Telephone: __________________
Address ________________________________________________________________________
Signature:________________________________________________________________________
Relationship to Applicant:____________________________________________________________
PA 1762 9/03
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Parent category: Financial