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Self Employment Income Form For use with Medicaid applications Applicant Name Case Number Date Date of Birth Home Address Mailing Address Phone Number Email Business/Trade Name* Business Information: Type of Business/Service Business Address* Tax ID/EIN* *IF APPLICABLE If yes, list names: Household Information: AND Each contributing household member must complete a separate self-employment income form with their contribution amount. Yes No Do other household members contribute to this business income? This form is used to report self-employment income and expenses if you are unable to provide a recent tax return from the previous year. Please complete the income and expense table for the past 6 months, beginning with the date your Medicaid application was first submitted. Attach proof of income and expenses when available. Acceptable documentation includes: REQUIRED DOCUMENTATION • Receipts or invoices for services provided • Bank statements showing deposits or withdrawals • Expense receipts (supplies, equipment, utilities, etc.) • Other proof of self-employment income or expenses If additional space is needed, you may attach extra sheets of paper or additional copies of this form. Once all fields have been filled out, the form may be submitted in-person, by email, or by mail. Reporting Period: This form covers income/ expenses from the following start and end dates. Start Date End Date Note: Gross Income – Total Expenses = Net Pay (Total Net Income Earned) Date Description of Service(s) Provided Gross Income Description of Expense(s) Paid Total Expenses Net Pay Total Gross Income Total Expenses Total Net Pay (Net Income) Client Signature Date Client Printed Name OR Disclaimer: We do not discriminate on the basis of race, ethnicity, color, national origin, religion, sex, age, or disability. Free language assistance services are available for people whose primary language is not English. We also provide free aids and services to assist with communicating the information effectively (such as interpreters, captioning, Braille, or large print). If you need these services, please contact us by phone or email. St Thomas/St. John District: 340-774-0930 ext. 4104 or sttjmap@dhs.vi.gov | St. Croix: 340-772-7100 or stxmap@dhs.vi.gov Privacy Notice: The information provided on this form will be used only for purposes of determining and verifying Medicaid eligibility. Your information is protected under state and federal privacy laws. FOR OFFICE USE ONLY Received by: Date: Client Prejury Statement: I, , hereby declare that I am self-employed and earn approximately $ or other from my self-employment. Under penalty of perjury, I certify that the information presented in this document is true and accurate to the best of my knowledge. By signing below, I understand that providing false statements may result in termination, denial, or recovery of benefits. Authorized Representative Signature Authorized Representative Name Phone Number Email Date Weekly Bi-weekly Monthly SIGN SIGN SIGN