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Peachcare. org SELF-EMPLOYMENT FORM FAMILY ACCOUNT NUMBER WEB CONFIRMATION NUMBER Directions Complete this form if you or another household member are self-employed. The form must be completed and signed for each household member who indicates or reports selfemployment. Use blue or black ink. Fax this form to 1-866-259-3404 or mail to PeachCare for Kids PO Box 2585 Atlanta GA 30301-2585. If you have any questions we can answer them. Call PeachCare for Kids at 1-877 GA PEACH 427-3224. The call is free. Name of Family Member who is Self-Employed Name of Business Type of Business Total gross self-employment income for the last four calendar weeks REQUIRED Write in your business expenses for all of the items below for the last four calendar weeks. If you have any questions we can answer them. Call PeachCare for Kids at 1-877 GA PEACH 427-3224. The call is free. Name of Family Member who is Self-Employed Name of Business Type of Business Total gross self-employment income for the last four calendar weeks REQUIRED Write in your business expenses for all of the items below for the last four calendar weeks. ALLOWABLE BUSINESS EXPENSE COVERING THE LAST 4 WEEKS 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 Employee Benefits Employer s FICA Share Employees Wages Interest of Farm/Business Loan Insurance of Property and Equipment IRS Allowable Business Expense Legal Fees for Business Meals and Equipment for Children in Day Care for DAY Care 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 Last 4 Weeks REQUIRED AMOUNT Parent Statement I certify under penalty of perjury that the information provide on this SelfEmployment Statement is true and correct. NOW YOU CAN AFFORD PEACE OF MIND Post Office Box 2583 Atlanta GA 30301-2583 1-877 GA PEACH 427-3224 Fax 1-866-259-3404 www. Use blue or black ink. Fax this form to 1-866-259-3404 or mail to PeachCare for Kids PO Box 2585 Atlanta GA 30301-2585. If you have any questions we can answer them* Call PeachCare for Kids at 1-877 GA PEACH 427-3224. The call is free. Name of Family Member who is Self-Employed Name of Business Type of Business Total gross self-employment income for the last four calendar weeks REQUIRED Write in your business expenses for all of the items below for the last four calendar weeks. ALLOWABLE BUSINESS EXPENSE COVERING THE LAST 4 WEEKS 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 Employee Benefits Employer s FICA Share Employees Wages Interest of Farm/Business Loan Insurance of Property and Equipment IRS Allowable Business Expense Legal Fees for Business Meals and Equipment for Children in Day Care for DAY Care 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 Last 4 Weeks REQUIRED AMOUNT Parent Statement I certify under penalty of perjury that the information provide on this SelfEmployment Statement is true and correct. .

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