Get WI F-00107 2013
WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00107 05/13 SEI SELF EMPLOYMENT INCOME REPORT Personally identifiable information will only be used for the direct administration of assistance programs. Month of Report month/year Today s Date Worker Name Agency Name Last First MI Case Number if known Home Address Business Name City State Zip Code Business Address if not your home address Street City State Zip Code INCOME AND EXPENSES Enter the amount for the previous month. Keep records such as receipts etc* that list the amounts you enter. For partnerships and corporations report income and expenses for the operation as a whole your share will be calculated later What percent of the business is owned by the applicant s listed above Income Number of hours worked this month 1. Gross receipts or sales net capital gains and other incomes Expenses Materials and supplies including office supplies Wages not including wages to yourself Commissions paid to your employees Vehicle expenses mileage insurance and maintenance Travel expenses for business away from home meals lodging transportation other than claimed in the car and truck category in line 5. Rent or lease on business property Repairs on business equipment and property Do not include vehicle costs as this will be entered on line 5. Business telephone and utility expenses 10. Freight or shipping expenses 11. Legal and professional services 12. Business taxes and licenses 13. Business insurance 14. Bank service charges to business. 15. Interest charged to business debt Do not include interest paid on rental property as this will be entered on line 21 16. Advertising expenses 17. Dues and publications 18. Depreciation 19. Depletion 20. Purchase of income-producing real estate capital assets and equipment and durable goods or principal payments on loans for the purchase price of these assets. 21. Interest payments on loans for the purchase price of income producing real estate capital assets and equipment and durable goods. 22. Other expenses not including transportation to and from work. a b c 23. TOTAL EXPENSES Add lines 2 through 22 and enter the amount. 24. NET BUSINESS INCOME or loss Subtract line 23 from line 1 and enter the amount. I hereby certify that the information given is accurate to the best of my knowledge. I understand that I may be required to present records and documents to support the figures given* Participant Signature Date Signed Privacy Law s. Month of Report month/year Today s Date Worker Name Agency Name Last First MI Case Number if known Home Address Business Name City State Zip Code Business Address if not your home address Street City State Zip Code INCOME AND EXPENSES Enter the amount for the previous month. Keep records such as receipts etc* that list the amounts you enter. For partnerships and corporations report income and expenses for the operation as a whole your share will be calculated later What percent of the business is owned by the applicant s listed above Income Number of hours worked this month 1. .
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