PeachCare Self Employment Form PDF Details

For families with self-employed members, managing healthcare costs has become more straightforward thanks to the PeachCare for Kids® Self-Employment Form. Located in Atlanta, Georgia, this initiative allows self-employed individuals to provide necessary information to apply for or continue their children's healthcare coverage. The form requires detailed entries about the self-employed household member's business, including the name, type of business, and a comprehensive breakdown of the gross self-employment income over the last four weeks. Moreover, it mandates disclosure of various business expenses, from advertising to travel costs, aiming to give a clear picture of the financial situation. Completing this form is crucial as it must be signed under the penalty of perjury, ensuring all provided information is true and accurate. Self-employed people can submit this document via fax or mail, following the straightforward instructions provided, ensuring they use either blue or black ink for clarity. This form not only streamlines the process of maintaining or acquiring health coverage for children but also underscores the importance of transparency and accuracy in reporting. With a dedicated phone line for assistance, the PeachCare for Kids® program makes it easier for self-employed individuals to navigate the complexities of healthcare coverage, emphasizing support and accessibility in the pursuit of health security for children.

QuestionAnswer
Form Name PeachCare Self Employment Form
Form Length 1 pages
Fillable? No
Fillable fields 0
Avg. time to fill out 15 sec
Other names self employment form ga, peachcare employment form, self employment gself pdf, peachcare tax form online

Form Preview Example

NOW YOU CAN AFFORD PEACE OF MIND

Post Office Box 2583

Atlanta, GA 30301-2583

1-877 GA PEACH (427-3224)

Fax 1-866-259-3404

www.peachcare.org

SELF-EMPLOYMENT FORM

FAMILY ACCOUNT NUMBER: _______________________________________

WEB CONFIRMATION NUMBER: _____________________________________

Directions: Complete this form if you or another household member are self-employed. The form must be completed and signed for each household member who indicates or reports self- employment. Use blue or black ink. Fax this form to 1-866-259-3404 or mail to PeachCare for Kids®, PO Box 2585, Atlanta, GA 30301-2585. If you have any questions, we can answer them. Call PeachCare for Kids® at 1-877 GA PEACH (427-3224). The call is free.

Name of Family Member who is Self-Employed: _________________________________________

Name of Business: ______________________ Type of Business: ___________________________

Total gross self-employment income for the last four calendar weeks: $ ___________ REQUIRED

Write in your business expenses for all of the items below for the last four calendar weeks.

ALLOWABLE BUSINESS EXPENSE COVERING THE LAST 4 WEEKS

 

AMOUNT

 

 

 

 

 

Advertising

 

 

$

Business License

 

 

$

Business Telephone Cost & Business Utilities Cost

 

 

$

Business Transportation (NOT to and from work)

 

 

$

Cost of Raw Materials, Farm Supplies & Feed, and Stock

 

 

$

Cost of Employee Benefits

 

 

$

Employer’s FICA Share

 

 

$

Employees’ Wages

 

 

$

Interest of Farm/Business Loan

 

 

$

Insurance of Property and Equipment

 

 

$

IRS Allowable Business Expense

 

 

$

Legal Fees for Business

 

 

$

Meals and Equipment for Children in Day Care (for DAY Care Business Only)

 

$

Operating Costs for Motor Vehicles for Business (gas, oil, etc.)

 

$

Office Supplies and Tools for Business

 

 

$

Postage

 

 

$

Property Taxes on Income Producing Property

 

 

$

Rent for Building Land, and/or Machinery/Equipment for Business

 

$

Repairs/Maintenance Equipment/Business Property

 

 

$

Travel/Lodging Away from Home

 

 

$

Tax Preparation Fee for Business

 

 

$

Total Business Expenses For The Last 4 Weeks

REQUIRED

 

$

Parent Statement: I certify under penalty of perjury, that the information provide on this Self- Employment Statement is true and correct.

___________________________________REQUIRED _______/________/_______ REQUIRED

Self-Employed Parent Signature

Date

GSELF

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