Form F-00107 at a glance
What it is: F-00107 (05/2026) is the Self-Employment Income Report of the Wisconsin Department of Health Services, Division of Medicaid Services.
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.
A filled-in Form F-00107 example: a lawn care owner reports one month
How to fill out Form F-00107, box by box
Name - Individual
In Section 1, Personal Information, enter the Name - Individual as Last, First, MI.
Case Number
Enter the Case Number.
Name - Business
In Section 2, Business Information, enter the Name - Business.
Type - Business
Enter the Type - Business.
Enter the Street Address, City, State and Zip Code.
Enter the Business Start Date and the Month/Year of Significant Change (if applicable).
Enter the Percent of Business Owned by Individual.
Business Income and Expenses
In Section 4, Business Income and Expenses, include income and expenses for the whole business, but do not include personal income and expenses.
Choose the Month of operation from the Choose One list.
Enter the Year of operation.
Enter the Number of hours individual worked for business during month of operation.
Business Income
Line 1 is Gross receipts and/or sales for your business.
Line 2 is Other business income, specify.
Business Expenses
Line 1 is Business wages and commissions paid to your employees.
Line 2 is Employee benefit programs, pensions, and profit sharing business expenses.
Line 3 is Business travel.
Line 4 is Business vehicle expenses.
Line 5 is Business rent or lease expenses.
Line 6 is Business repairs and maintenance expenses.
Line 7 is Business telephone and utilities expenses.
Line 8 is Business materials and supplies expenses.
Line 9 is Business freight expenses.
Line 10 is Business legal and professional fees.
Line 11 is Business advertising, dues, and publications expenses.
Line 12 is Business taxes (does not include income taxes).
Line 13 is Business insurance expenses.
Capital assets, depreciation and other business expenses
Line 14 is Purchase price of income-producing real estate, capital assets, capital equipment, and durable goods for your business.
Line 15 is Principal payment on loans for the purchase of income-producing real estate, capital assets, capital equipment, and durable goods for your business.
Line 16 is Business depreciation.
Line 17 is Business depletion.
Line 18 is Business amortization.
Line 19 is Other business expenses, specify.
Other business expenses, specify
Line 20 is Other business expenses, specify.
Line 21 is Other business expenses, specify.
More rules for Form F-00107
See the Self-Employment Income Report Completion Instructions, F-00107A, at https://www.dhs.wisconsin.gov/library/collection/f-00107 for information on filling out this form.
Section 3, Signature and Date, has SIGNATURE and Date Signed.
Common questions about Form F-00107
What am I certifying when I sign?
By signing this form, you are saying that the information you provided is correct and complete to the best of your knowledge.
Sources
[1] Form F-00107 (05/2026), Self-Employment Income Report, Wisconsin Department of Health Services (the Official source link on this page).