Statement of Self-Employment Income

Statement of Self‑Employment Income

*1. Name of person with Self‑Employment Income

*2. Number of months covered by this Income Statement

*3. Describe what person did to earn this money

List Business Expenses and Amount

Date	Expense	Amount

List Business Income and Amount

Date	Income Source	Amount

Total Expenses

Total Income

The above information is true, correct, and complete to the best of my knowledge. I understand that giving false information to the provider could result in my being disqualified for fraud.

Signature of person helping to complete this form

Date

*Applicant Signature

*Date