HTML Preview Self Employment Verification Form page number 1.
Self-Employment Verification Form
Parent/Guardian Name:
Business Name: Business Name: Business Address: Business Address:
Business Phone # ______________________
Please check the appropriate boxes below. Submit requested documentation with this completed form.
YES NO
1.
Do you have a business license to conduct business in Stanislaus County or a neighboring
county? (If so, please attach)
2.
Do you have a professional license? (If so, please attach)
3.
Is your office or place of work also your residence or located at your residence?
4.
Is your office or place of work a rented property?
5.
Do you have regular business hours? (If so, please attach)
6.
Do you work for others on a contract basis?
7.
Do you have advertising materials? (If so, please attach)
Please check the appropriate box below and describe the primary nature of your self-employment:
Sales (real estate, retail business, etc.)
Landscape / Gardening (landscaping, landscape design, etc.)
Domestic (house-cleaning business, etc.)
Trucking (owns truck/trucking business, works for a company as an independent contractor, etc.)
Other (Please describe.)
Please select the box that best describes the basis for your income and tell how much you typically earn for
that item and how many of those items you would be paid for in a month.
(Example:
Per haul $75 per haul, 22 hauls per month)
Commission Per job
Per sale Per piece
Per mile Per haul
Per item completed Other (Please describe)
Please document your schedule below:
Total number of hours per day normally worked
Average number of
days per week normally worked
Do days worked vary? Yes or No
Do work hours vary? Yes or No
Time normally worked: AM/PM to AM/PM
Circle the days normally worked S M T W TH F S
I swear under penalty of perjury, to the best of my knowledge, that the above information is true and correct.
Parent / Guardian Signature: Date:
If you have any questions, please contact a Child Care Specialist at (209) 238-6300.