SE Income Worksheet
Self-Employment Income Worksheet For Agency Use Only:
Dear [Primary Applicant Name],
You told us that you or someone in your household is self-employed. We need more information from you to process your application. We need proof of your self-employment income. Please fill out the attached worksheet, sign it, and return it to us by the due date. If we do not receive the form your medical assistance will be application will be denied or discontinued. The information is due no later than [due date].
Business Income
Tell us about your business income.
|Name of Self-employed person |[auto-filled by the worker] |
|Case Number |[auto-filled by the worker] |
|Type of Business |[auto-filled by the worker] |
|Name of Business |[auto-filled by the worker] |
|Date Business Started |[auto-filled by the worker] |
|Please list the amount of gross income for each of the months listed. Note: Gross income is the total before you pay expenses. |
|Month |Gross Monthly Income |Month |Gross Monthly Income |
| |$ | |$ |
| |$ | |$ |
| |$ | |$ |
| |$ | |$ |
| |$ | |$ |
| |$ | |$ |
Signature: This worksheet must be signed and dated.
________________________________________________________________
Signature Date
If you need assistance in completing this form please call (_____) ________________ between the hours of ______ am to _______ pm.
Business Expenses
Tell us about your business expenses.
|There are many types of business expenses. You might not have all of these. List the amount you have for each category below. If you don’t have that expense, leave the box blank. Put the amount of the expense for |
|every month listed. |
|Month |
|Month |
Month | | | | | | | | | | | | | |Type of Expense |Amount |Amount |Amount |Amount |Amount |Amount |Amount |Amount |Amount |Amount |Amount |Amount | |Car and truck expenses | | | | | | | | | | | | | |Chemicals | | | | | | | | | | | | | |Conservation expenses | | | | | | | | | | | | | |Custom hire (machine work) | | | | | | | | | | | | | |Depreciation | | | | | | | | | | | | | |Employee benefit programs | | | | | | | | | | | | | |Feed | | | | | | | | | | | | | |Fertilizers and lime | | | | | | | | | | | | | |Freight and trucking | | | | | | | | | | | | | |Gasoline, fuel, and oil | | | | | | | | | | | | | |Insurance (other than health) | | | | | | | | | | | | | |Interest | | | | | | | | | | | | | |Labor hired | | | | | | | | | | | | | |Pension and profit-sharing plans | | | | | | | | | | | | | |Rent or lease | | | | | | | | | | | | | |Repairs and maintenance | | | | | | | | | | | | | |Seeds and plants | | | | | | | | | | | | | |Storage and warehousing | | | | | | | | | | | | | |Supplies | | | | | | | | | | | | | |Taxes | | | | | | | | | | | | | |Utilities | | | | | | | | | | | | | |Veterinary, breeding, and medicine | | | | | | | | | | | | | |Other: __________ | | | | | | | | | | | | | |Other: __________ | | | | | | | | | | | | | |For more information related to allowable self-employment expenses, please visit the Internal Revenue Service’s website at .
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