Medical Renewal Form Page 5
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9Case name:
Case number:
Date of request:
2. Tell us about any money from self-employment:
Send all available proof of income and expenses for the most recent month available.
Proof could be bookkeeping records, contracts, work agreements, payroll records or sales
receipts. Tax returns may also be accepted if no other proof is available.
Business name:
What does this business do?
Is this business incorporated? Yes No
Is your office located within your home? Yes No
Business address:
City:
State:
Business phone number:
Gross income expected this
Gross income expected next
month (before costs)?
month (before costs)?
1
business expense: Kind of expense
How much this month? How much next month?
st
2
nd
business expense: Kind of expense
How much this month? How much next month?
3
rd
business expense: Kind of expense
How much this month? How much next month?
4
th
business expense: Kind of expense
How much this month? How much next month?
5
th
business expense: Kind of expense
How much this month? How much next month?
Please use another sheet of paper if you need to write about more businesses or expenses.
3. Please tell us about money for this month and next month that does not come from work.
If yes, tell us about this month’s and next month’s income for anyone in your home who is
related to you or your children (including expected children).
You must send proof. Proof could be copies of check stubs, award letters, or
other written proof.
Tell us about money, including:
• rent paid to you
• loans repaid to you
• guardian or foster care payments
• tribal payments
• worker’s compensation
• Supplemental Security Income (SSI)
• disability benefits
• child or spousal support
• unemployment compensation
• veteran’s benefits
• Social Security benefits
• dividends or interest on investment
• retirement pension
• educational income (such as financial aid)
• Temporary Assistance for Needy Families (TANF)
• other: _______________________
Please list money that does not come from work:
1
st
kind of income: Write kind of income here.
Who gets this income? How much gross income:
this month? next month?
What person, business or agency pays this person?
How often?
Every week
Every 2 weeks
Every month
2
nd
kind of income: Write kind of income here.
Who gets this income? How much gross income:
this month? next month?
What person, business or agency pays this person?
How often?
Every week
Every 2 weeks
Every month
Please use another sheet of paper if you need to tell us about more money form other places.
?
?
Need help?
Please call your worker. The phone number is at the top of the first page.
Page 5
OHA 0945 (06/12)
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Parent category: Business