Self-Employment Form (Page 2 of 2) in pdf

-E

ELF

MPLOYMENT

ORM

PLEASE PRINT CLEARLY

BUSINESS INCOME CALCULATION WORKSHEET

Family ID #:

Please round all amounts to the nearest dollar.

1. Income

What this is.

Amount

1a. Gross Income Earned

Enter your gross business income before deductions.

From:

1b. Period Covered

Tell us how long it took you to earn this money.

To:

2. Business Expenses

You can claim the standard mileage deduction if you use

Miles ________ x $0.535

2a. Car and Truck Expenses

your car or truck for business purposes. Multiply the

= $ ____________

miles you traveled for work times $0.535 per mile.

List the amount you pay for business insurance on your

2b. Insurance

business.

Enter the cost of renting vehicles, machinery or

2c. Equipment Rental

equipment for your business.

Enter the cost of supplies and materials used to operate

2d. Supplies

your business.

Enter the cost of any licenses you purchased for your

2e. Licenses

trade or business.

Enter your business telephone expense. If you use your

2f. Telephone

home telephone for business, do not deduct the regular

monthly rate charged by your telephone company.

Enter the amount you paid to individuals that worked for

2g. Employee Salaries

you. Do not include payments to yourself or any other

business owners.

3. Total Business Expenses

Add the total expenses listed in line 2a through line 2g.

Subtract the total expenses in line 3 from your gross

4. Net Business Income

earnings in line 1a.

Certification: (Please read carefully and sign below.)



I certify that the information I have provided is true and correct.



I understand and agree that Care 4 Kids may independently verify the information given on this form.



I understand that Care 4 Kids may contact the Internal Revenue Services or the State Department of Revenue services to verify

information concerning my business income.

I have read this statement or I have had it read to me in my native language. I also certify that all statements made by me and all the

information on this form are true and correct under penalty for false statement as provided in either Section 53a-15b or Section

17b-97 of the Connecticut General Statues.

Business Owner Signature:

Date:

Complete and return this form to:

Care 4 Kids Program, 1344 Silas Deane Highway, Rocky Hill, Connecticut 06067

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

Rev. 04/17

Self-Employment Form Page 2

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