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 not provided: if you do not provide your self-employment income, you may not be able to get or keep getting benefits.
Business income and expenses: include income and expenses for the whole business, but do not include personal income and expenses.
Signing: by signing this form, you are saying that the information you provided is correct and complete to the best of your knowledge.
Instructions: see the Self-Employment Income Report Completion Instructions, F-00107A, for information on filling out this form.
| Question | Answer |
|---|---|
| Form Name | F-00107 |
| Form Length | 3 pages |
| Fillable? | Yes |
| Fillable fields | 184 |
| Avg. time to fill out | 31 min |
| Edition | 05/2026 |
| Issuing agency | Wisconsin Department of Health Services Division of Medicaid Services |
| Matches the agency's file | Yes, checked October 2, 2026 |
| Other names | F-00107, F00107, Form F-00107, SEI, Self-Employment Income Report, Wisconsin self employment income report form |
| Official source | F-00107 (Rev 05/2026), Wisconsin Department of Health Services Division of Medicaid Services |
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