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Self-Employment Verification Page 1
SELF-EMPLOYMENT VERIFICATION
INCOME AND EXPENSES
This form is to record income and expenses for self-employment FOR THE LAST 3 MONTHS and
must be supported with receipts. This information is confidential and will be used only to determine
your eligibility for child care assistance. The information will not be released without your written
consent. However, staff from Workforce Solutions Northeast Texas Child Care Services may
contact sources listed on this form to verify the information. Incomplete forms will result in the delay
and/or the termination/denial of child care services.
I, _______________________________, am providing this written statement of my income and
Self Employed Individual
expenses from my __________________________________________ business for the period
Business Name/Type
beginning ________________________and ending __________________________.
(beginning month/year) (ending month/year)
1. Complete Attachment I- Gross Income Enter total gross income: $_____________
2. Complete Attachment II- Expenses Enter total expenses: $_____________
3. Subtract total expenses from total income Enter Net Income: $_____________
If my work hours cannot be verified by valid documentation, I understand that my income will be
divided by the Federal Minimum Wage of $7.25 per hour to establish whether or not I am meeting
the required minimum participation hours of 25 hours per week (single parent family) or 50 hours
per week (2 parent family).
Example: You are a single parent. You have gross income of $896.00/month. There are 4.33 weeks in a
month. $896.00 (income) ÷ $7.25 (minimum wage) ÷ 4.33 (weeks per month) = 28.5 hours per week.
I understand that I must provide a copy of my most current tax return including a Schedule C OR
notarized statement explaining why I do not have a tax return for my business.
I HEREBY CERTIFY under penalty of perjury, that the information I provided to Child Care Services
is true and accurate.
________________________________________ _____________________________
Signature Date