Self Employment Statement Form
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1Self Employment Statement
Directions: Complete this form if you or another household member are self-employed. This form must be
signed by the self-employed household member(s). Use blue or black ink. Return the completed form to
Florida KidCare, PO Box 591, Tallahassee, Florida 32302-0591. If you have questions, please call Florida
KidCare toll-free at 1-800-821-KIDS (5437).
Family Account Number:
Name of Family Member(s) who are Self-Employed: _______________________________________
Name of Business: ____________________________ Type of Business: _____________________
Total gross (before taxes) self-employment income for the most recent month: $______________
Write in your business expenses for all of the items below for the most recent month:
ALLOWABLE BUSINESS EXPENSES
AMOUNT
Advertising
$
$
Business License
$
Business Telephone Cost & Business Utilities Cost
$
Business Transportation (NOT to and from work)
$
Cost of Raw Materials, Farm Supplies & Feed, and Stock
$
Cost of Employees Benefits
$
Employer’s FICA Share
$
Employees’ Wages
$
Interest of Farm/Business Loan
$
Insurance on Property and Equipment
$
IRS Allowable Business Expense
$
Legal Fees for Business
$
Meals and Equipment for Children in Day Care (for DayCare Business ONLY)
$
Operating Costs for Motor Vehicles for Business (gas, oil, etc.)
$
Office Supplies and Tools for Business
$
Postage
$
Property Taxes on Income Producing Property
$
Rent for Building, Land, and/or Machinery/Equipment for Business
$
Repairs/Maintenance Equipment/Business Property
$
Travel/Lodging Away from Home
$
Tax Preparation Fee for Business
$
TOTAL BUSINESS EXPENSES FOR THE MOST RECENT MONTH:
If your self-employment income and expenses usually are different from what you have listed, use this space to
tell us about the difference._______________________________________________________
____________________________________________________________________________________
________________________________________________________________________________________
________________________________________________________________________________
Parent Statement: I certify that the information provided on this Self-Employment Statement is true and
correct to the best of my knowledge. I understand that this information may be verified. I understand if I
provide false information I may be prosecuted for fraud.
________________________________________________________ ________________
Self-Employed Parent Signature(s)
Date
Si usted prefiere recibir su correspondencia en español, por favor llame sin cargo al 1-800-821- 5437.
T04p
Si-ou ta vié enfômasyon sa-a an Kréyol, tanpri rélé 1-800-821-5437 gratis.
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