Every year, taxpayers must file an income tax return with the IRS. The form used to report income and tax information is Form 1040. Along with Form 1040, taxpayers must also submit a variety of supporting documents, including Schedule A (Itemized Deductions) and Schedule C (Profit or Loss from Business). In certain circumstances, taxpayers may be required to file additional forms as well. One such form is Form 3054-A, which is used by farmers and fishermen to report their self-employment income. Let's take a closer look at this form and how it should be completed.
| Question | Answer |
|---|---|
| Form Name | Form 3054 |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | form 3054 dads time sheets 2015, form 3054 dads, texas form 3054, texas department of aging and disability services forms |
Texas Department of Aging
and Disability Services
Primary Home Care
Service Delivery Record
Form 3054
August
Month and Year of Service
Home and Community Support Services Agency
Contract No.
Employee Name/No.
If more than one employee serves the individual, list employee name(s):
Individual Name
Individual ID No.
County
Task(s) Assigned (for Family Care and Primary Home Care only):
Bathing
Dressing
Exercising
Feeding
Grooming
Laundry
Toileting
Transfer
Cleaning
Routine Hair/Skin Care
Meal Preparation
Escort
Shopping
Assist with
Ambulation
Other (specify)
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Note:Billing for services not actually provided |
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Scheduled or Authorized Hours |
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constitutes fraud. |
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Day |
In |
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Out |
Total |
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Day |
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In |
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Out |
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Total |
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Day |
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In |
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Out |
Total |
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Sunday |
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Wednesday |
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Saturday |
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Monday |
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Thursday |
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Total Authorized Hours Per |
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Tuesday |
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Friday |
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Week: |
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Record of Time |
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Time (Hours:Minutes AM/PM) |
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Time (Hours:Minutes AM/PM) |
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Time (Hours:Minutes AM/PM) |
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Day of |
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Time in |
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Time out |
Total Daily |
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Day of |
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Time in |
Time out |
Total Daily |
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Day of |
Time in |
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Time out |
Total Daily |
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Month |
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Time |
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Month |
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Time |
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Month |
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Time |
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1 |
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12 |
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23 |
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2 |
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13 |
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24 |
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3 |
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14 |
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25 |
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4 |
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15 |
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26 |
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5 |
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16 |
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27 |
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6 |
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17 |
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28 |
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7 |
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18 |
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29 |
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8 |
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19 |
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30 |
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9 |
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20 |
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31 |
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10 |
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21 |
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Monthly Total of Hours: |
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11 |
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22 |
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This is to certify that I worked the hours recorded and completed the work tasks assigned.
Signature – Employee
This is to certify that to the best of my knowledge the employee has worked the hours recorded and
completed the tasks assigned.
Signature – TimekeeperDate*
*The date indicated here must not be before the last day the provider worked.