SELF EMPLOYMENT REPORTING FORM & WORKSHEET

Name:	Reporting Period:
Social Security Number:	Type of Business:
Number of hours you worked at Self Employment during this Reporting Period?

INCOME: Sales, wages from sale of service, tips, other earned income, etc
$
$
$
$
$
TOTAL GROSS INCOME	$
EXPENSES: Cost of supplies for your business, business expenses for your vehicle, other self employment expenses, etc
$
$
$
$
$
TOTAL EXPENSES	$

Total Gross Income	$	Net Income	$
Minus Total Expenses	$	Divided by Federal Minimum Wage	$7.25
Equals Total Net Income	$	Total number of countable hours for the month

By signing this, I certify that the above information is true and reported correctly.

Participant Signature:	Date: