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Get Self Employment Statement

Self Employment Statement Directions Complete this form if you or another household member are self-employed. This form must be signed by the self-employed household member s. Parent Statement I certify that the information provided on this Self-Employment Statement is true and correct to the best of my knowledge. Use blue or black ink. Return the completed form to Florida KidCare PO Box 591 Tallahassee Florida 32302-0591. If you have questions please call Florida KidCare toll-free at 1-800-821-KIDS 5437. Family Account Number Name of Family Member s who are Self-Employed Name of Business Type of Business Total gross before taxes self-employment income for the most recent month Write in your business expenses for all of the items below for the most recent month ALLOWABLE BUSINESS EXPENSES AMOUNT Advertising Business License Business Telephone Cost Business Utilities Cost Business Transportation NOT to and from work Cost of Raw Materials Farm Supplies Feed and Stock Cost of Employees Benefits Employer s FICA Share Employees Wages Interest of Farm/Business Loan Insurance on Property and Equipment IRS Allowable Business Expense Legal Fees for Business Meals and Equipment for Children in Day Care for DayCare Business ONLY Operating Costs for Motor Vehicles for Business gas oil etc. Office Supplies and Tools for Business Postage Property Taxes on Income Producing Property Rent for Building Land and/or Machinery/Equipment for Business Repairs/Maintenance Equipment/Business Property Travel/Lodging Away from Home Tax Preparation Fee for Business TOTAL BUSINESS EXPENSES FOR THE MOST RECENT MONTH If your self-employment income and expenses usually are different from what you have listed use this space to tell us about the difference. Use blue or black ink. Return the completed form to Florida KidCare PO Box 591 Tallahassee Florida 32302-0591. If you have questions please call Florida KidCare toll-free at 1-800-821-KIDS 5437. Family Account Number Name of Family Member s who are Self-Employed Name of Business Type of Business Total gross before taxes self-employment income for the most recent month Write in your business expenses for all of the items below for the most recent month ALLOWABLE BUSINESS EXPENSES AMOUNT Advertising Business License Business Telephone Cost Business Utilities Cost Business Transportation NOT to and from work Cost of Raw Materials Farm Supplies Feed and Stock Cost of Employees Benefits Employer s FICA Share Employees Wages Interest of Farm/Business Loan Insurance on Property and Equipment IRS Allowable Business Expense Legal Fees for Business Meals and Equipment for Children in Day Care for DayCare Business ONLY Operating Costs for Motor Vehicles for Business gas oil etc* Office Supplies and Tools for Business Postage Property Taxes on Income Producing Property Rent for Building Land and/or Machinery/Equipment for Business Repairs/Maintenance Equipment/Business Property Travel/Lodging Away from Home Tax Preparation Fee for Business TOTAL BUSINESS EXPENSES FOR THE MOST RECENT MONTH If your self-employment income and expenses usually are different from what you have listed use this space to tell us about the difference. .

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