Self-Employment Work Sheet Fill out the online application below or download and print the Self Employment WS PDF "*" indicates required fields Section 1Self-Employment DisclaimerName of Self-Employed Person* Name of Business* Type of Business* Is your business run out of your home* Yes No Relationship to Applicant* Applicant Name (if different) Section 2Income for the last month from your businessGross Income (before business deductions)*Adjusted Gross Income (after business deductions)*Section 3DocumentationWhat did you use to compute your self-employment income?* Receipts Log book Quarterly Tax Return Worksheet Other What did you use? Section 4Rent, Food & Utilities (Fill out completely ONLY if adjusted gross income is zero or negative) How much is your household required to pay for rent/mortgage?Does your household get help paying rent/mortgage? Yes No Who helps pay? Where did the money come from to pay that rent/mortgage payment? How did you pay for food last month? How much are the estimated monthly utility costs?If they were paid last month, where did the money come from to pay for the utilities last month? Section 5Certify Statement* I certify that the information contained above is complete and accurate to the best of my knowledge. I understand that I am electronically signing this statement under penalty of prosecution if I knowingly give false information to receive assistance for which I am not eligible. By checking this box and typing my name below, I am electronically signing this form. Signature of Self-employed Person* Date*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920CAPTCHAPhoneThis field is for validation purposes and should be left unchanged.