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]
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
Type of Expense	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount
Advertising
Car and truck expenses
Commissions and fees
Contract Labor
Depletion
Depreciation
Employee benefit programs
Insurance
Interest
Legal and professional services
Office expenses
Pension and profit-sharing plans
Rent or lease
Vehicles, machinery, and equipment
Other business property
Repairs and maintenance
Supplies
Taxes and Licenses
Travel, meals, and entertainment
Utilities
Wages
Other: __________
Other: __________

For more information related to allowable self-employment expenses, please visit the Internal Revenue Service’s website at www.irs.gov.

Rental Property Expenses

Tell us about your rental property expenses. If you have more than one property, add the expenses together and give us one amount.

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
Type of Expense	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount	Amount
Advertising
Auto and travel
Cleaning and maintenance
Commissions
Insurance
Legal and other professional fees
Management fees
Mortgage interest paid to banks, etc.
Other Interest
Repairs
Supplies
Taxes
Utilities
Depreciation or depletion
Other: __________
Other: __________
Other: __________

For more information related to allowable self-employment expenses, please visit the Internal Revenue Service’s website at www.irs.gov.

Farming Expenses

Tell us about your farming 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
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 www.irs.gov.