Self Employment Income Report Form PDF Details

For many self-employed individuals, tracking and reporting income can seem like navigating through a labyrinth, but understanding the essentials of the Self Employment Income Report form may shine a beacon of light on this daunting process. Issued by the Wisconsin Department of Health Services, this form serves as a critical tool for those aiming to qualify for certain state-provided programs like BadgerCare Plus, FoodShare, or Medicaid for the Elderly, Blind, or Disabled. Its primary purpose is not to overcomplicate life but to verify income eligibility in a straightforward manner. Interestingly, the form highlights the flexibility of reporting, stating that self-employment income can also be submitted through alternative means such as tax returns or bookkeeping records, emphasizing the importance of accurate income declaration to maintain or gain access to vital benefits. It meticulously requires personal and business information, ensuring that the information provided is both accurate and comprehensive to the best of the filer’s knowledge. Furthermore, it delves into the specifics of business income and expenses, covering everything from gross receipts to depreciation, thus providing a comprehensive framework for self-employed individuals to document their financial operations. With careful attention to detail, this form not only aids in legal and program compliance but also encourages a thorough examination of one's business finances.

QuestionAnswer
Form NameSelf Employment Income Report Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesself employment income report form wi, self employment report, self employment income verification form, wisconsin self employment income report

Form Preview Example

WISCONSIN DEPARTMENT OF HEALTH SERVICES

Division of Medicaid Services

F-00107 (06/2019)

SELF-EMPLOYMENT INCOME REPORT

SEI

The information you provide on this form will only be used to see if you meet the income rules for programs such as BadgerCare Plus, FoodShare, or Medicaid for the Elderly, Blind, or Disabled. This form is not the only way you can provide information about your self-employment income. You can provide the information in another way, such as through tax returns or bookkeeping records. If you do not provide your self-employment income, you may not be able to get or keep getting benefits.

See the Self-Employment Income Report Completion Instructions, F-00107A, at https://www.dhs.wisconsin.gov/library/ f-00107.htm for information on filling out this form.

SECTION 1 Personal Information

Name – Individual (Last, First, MI)

Case Number

SECTION 2 Business Information

Name – Business

Type – Business

Street Address

City

 

State

Zip Code

 

 

 

 

 

Business Start Date

Month/Year of Significant Change (if applicable)

Percent of Business Owned by Individual

 

 

0.00%

 

 

 

 

 

 

 

SECTION 3 Signature and Date

By signing this form, you are saying that the information you provided is correct and complete to the best of your knowledge.

SIGNATURE

Date Signed

Wis. Stat. § 15.04(1)(m)

SEI

SECTION 4

Business Income and Expenses (include income and expenses for the whole business)

Month of operation:

CHOOSE ONE

 

CHOOSE ONE

 

CHOOSE ONE

 

 

 

 

 

 

Year of operation:

 

 

 

 

 

 

 

 

 

 

 

Number of hours individual worked for business during

 

 

 

 

 

month of operation:

 

 

 

 

 

A. Gross Business Income

Amount

Amount

Amount

 

 

 

 

 

 

1.Gross receipts and/or sales

2.Other income, specify:

B.

Gross Business Expenses

Amount

Amount

Amount

 

 

 

 

 

1.

Wages and commissions paid to employees

 

 

 

 

 

 

 

 

2.

Employee benefit programs, pensions, and profit

 

 

 

 

sharing

 

 

 

3.

Travel

 

 

 

 

 

 

 

 

4.

Vehicle

 

 

 

 

 

 

 

 

5.

Rent or lease

 

 

 

 

 

 

 

 

6.

Repairs and maintenance

 

 

 

 

 

 

 

 

7.

Telephone and utilities

 

 

 

 

 

 

 

 

8.

Materials and supplies

 

 

 

 

 

 

 

 

9.

Freight

 

 

 

 

 

 

 

 

10.

Legal and professional fees

 

 

 

 

 

 

 

 

11.

Advertising, dues, and publications

 

 

 

 

 

 

 

 

12.

Taxes (does not include income taxes)

 

 

 

 

 

 

 

 

13.

Insurance

 

 

 

 

 

 

 

 

14.

Purchase price of income-producing real estate, capital

 

 

 

 

assets, capital equipment, and durable goods

 

 

 

15.

Principal payment on loans for the purchase of income-

 

 

 

 

producing real estate, capital assets, capital equipment,

 

 

 

 

and durable goods

 

 

 

16.

Depreciation

 

 

 

 

 

 

 

 

17.

Depletion

 

 

 

 

 

 

 

 

18.

Amortization

 

 

 

 

 

 

 

 

19.

Other expenses, specify:

 

 

 

 

 

 

 

 

20.

Other expenses, specify:

 

 

 

 

 

 

 

 

21.

Other expenses, specify:

 

 

 

 

 

 

 

 

F-00107

Page 2 of 2

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1. It's important to complete the self employment report accurately, thus be careful when filling in the areas comprising these blanks:

Part # 1 of submitting proof of self employment form

2. Once your current task is complete, take the next step – fill out all of these fields - By signing this form you are, SIGNATURE, Date Signed, and Wis Stat m with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

The way to prepare proof of self employment form part 2

It is possible to make errors while completing the SIGNATURE, and so make sure to look again before you finalize the form.

3. Your next stage is hassle-free - fill in all of the form fields in Month of operation, Year of operation, Number of hours individual worked, Choose One, Choose One, Choose One, A Gross Business Income, Amount, Amount, Amount, Gross receipts andor sales, Other income specify, B Gross Business Expenses, Amount, and Wages and commissions paid to to finish the current step.

Gross receipts andor sales, Other income specify, and Amount in proof of self employment form

4. This fourth paragraph arrives with all of the following blank fields to type in your specifics in: Freight, Legal and professional fees, Advertising dues and publications, Taxes does not include income, Insurance, Purchase price of incomeproducing, assets capital equipment and, Principal payment on loans for, Depreciation, Depletion, Amortization, and Other expenses specify.

proof of self employment form completion process described (stage 4)

5. Last of all, this last section is precisely what you should wrap up prior to using the document. The blank fields under consideration are the following: Other expenses specify, Other expenses specify, and Page of.

The best way to fill out proof of self employment form part 5

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