Self-Employment Form printable pdf download

-E

ELF

MPLOYMENT

ORM

PLEASE PRINT CLEARLY

Name (First, Last):

Family ID #:

Home Address:

Street

City

State

Zip Code

Business Name:

Business Address:

Street

City

State

Zip Code

Type of Business (explain):

Business Owner Name(s) 1:

Business Phone:

When was this business started?

Month/Year

Did you file a business tax return last year?  Yes  No

At application, self-employed individuals must be earning taxable income at the time they initially request assistance.

At redetermination, self-employed individuals must be earning an hourly wage that is at or above State of Connecticut’s current minimum wage. This is

calculated based on the weekly or monthly income earned divided by the number of hours involved in the work activity. Individuals should submit the

verification that shows the current business income.

Instructions

1. You may use the worksheet on the back of this form to verify your self-employment income if:



You did not file a business income tax return last year; or



You filed a business tax return last year and expect a significant change in your business earnings this year.

2. You must have business records to verify the information given on this form. Business records include items such as invoices,

cancelled checks, receipts for materials purchased, bank account information and your business calendar for us to determine

your work schedule. Please send copies. We cannot guarantee that original forms will be returned to you.

Note: This form lists only lists the most common business deductions allowed by the IRS. If you claim other deductions, such as

depreciation, you must include a worksheet showing how you calculated the expense.

3. If you filed a business tax return last year, please include copies of forms IRS 1040 and Schedule C. Include form 8829 if you

claim expenses for the business use of your home.

4. If you own a corporation or partnership, include copies of IRS forms 1120 and 1065. Your share of profits not distributed to the

principal owners will be counted as income.

5. Please include copies of any estimated taxes you paid to the IRS this year. Generally, the IRS requires you to make estimated tax

payments if you expect to owe at least $1,000 in taxes.

6. State or federal law may not allow deductions for the cost of depreciation, the purchase of tools or equipment, entertainment

expenses, or prior year business losses. If you claim an expense that is not allowed, we will add the amount to the net income

reported on this form.

7. We must be able verify how many hours you work and the work schedule you listed on your application form. Please send us

any information you have that verifies your work schedule.

If you have any questions or need help completing this form, please call Care 4 Kids at 1-888-214-5437.

Care 4 Kids is a program of the State of Connecticut Office of Early Childhood.

Rev. 04/17

Self-Employment Form

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