Hawaii DHS 1109 Report of Self Employment Earnings

Dhs Form 1109 PDF Details

Form DHS 1109 (11/18), the Report of Self-Employment Earnings, is used by the Med-QUEST Division of the Hawaii Department of Human Services to verify a self-employed applicant's or beneficiary's income. Part I carries the case name and number and the EB worker's name, phone and unit address. Part II names the self-employed person, the business, its nature and its principal place. Part III asks seven yes or no questions that decide whether the person is self-employed: selling a service or product for profit, bearing independent costs, paying a general excise license fee, paying both shares of social security taxes, and holding a current Hawaii general excise license; verification goes with each question marked with an asterisk. Part IV records the gross self-employment income for the month or year, the business expenses (general excise license fee and tax, other), the total expenses and the net earned income. The person signs and dates the form.