Peachcare Self Employment Form PDF Details

Are you a self-employed individual looking for coverage for you and your family? Peachcare may be the ideal fit for you! Our goal is to make sure individuals and families have access to quality healthcare, regardless of their employment status. With that in mind, this blog post outlines the process of completing the Peachcare Self-Employment Form - providing all the step by step instructions needed so you can easily get insured with us. Whether this is your first time filling out a form like this or if it’s been a while since the last one - don’t worry! We will walk through each section and provide helpful tips along the way. Read on to learn everything you need to know about submitting your application today!

QuestionAnswer
Form NamePeachcare Self Employment Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesself 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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For you to complete this PDF document, be sure to enter the information you need in each and every blank field:

1. It's essential to fill out the peachcare tax form online properly, so take care when working with the areas that contain these particular fields:

Writing section 1 in peachcare employment form

2. When the previous array of fields is done, it is time to include the necessary details in Advertising Business License so you're able to move on further.

Writing part 2 of peachcare employment form

As to Advertising Business License and Advertising Business License, be certain you do everything right in this section. Both of these are surely the most important fields in this PDF.

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GSELF, Date, and Advertising Business License of peachcare employment form

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