Form 470-3784 at a glance
What it is: The Self-Employment Ledger is a form that lists INCOME and EXPENSE.
Where and when to file: Information is due upon HHS request.
A filled-in Form 470-3784 example: a client lists a month of sales and one expense
How to fill out Form 470-3784, box by box
Case Name, SSN, Worker and Case Number
Enter the Case Name, SSN, Worker and Case Number.
Month and date
Enter the MONTH and the DATE.
Date, item, income and expense
On each line, enter the DATE, ITEM, INCOME and EXPENSE.
More rules for Form 470-3784
Copy 1 is the Client copy and Copy 2 is the Case Record copy.
Common questions about Form 470-3784
Is there a deadline?
Information is due upon HHS request.
Sources
[1] Form 470-3784 (Rev. 08/23), Self-Employment Ledger, Iowa Department of Health and Human Services (the Official source link on this page).
