Self- Employment Verification Form Page 3
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6SELF-EMPLOYMENT WORK HOURS & INCOME
Parent/Guardian Name:
Self-Employment Work Hours/Income
**The customer who signs the receipts or invoices must be available by phone to verify the information, if needed.
WEEK ONE:
Dates: ___________ thru __________
WEEK TWO:
Dates: ___________ thru ___________
Monday
Monday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Tuesday
Tuesday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Wednesday
Wednesday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Thursday
from ______ AM/PM to ______ AM/PM $_______
Thursday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Friday
Friday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Saturday
Saturday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Sunday
Sunday
TOTAL NUMBER OF HOURS, WEEK ONE: ______________
TOTAL NUMBER OF HOURS, WEEK TWO: ______________
TOTAL INCOME EARNED, WEEK ONE:________________
TOTAL INCOME EARNED, WEEK TWO:________________
TOTAL NUMBER OF CUSTOMERS SERVED:_____________
TOTAL NUMBER OF CUSTOMERS SERVED:_____________
**Name and phone number of customers served this
**Name and phone number of customers served this
week must be on receipts or invoices:
week must be on receipts or invoices:
WEEK THREE:
Dates:___________ thru ___________
WEEK FOUR:
Dates: ___________ thru ___________
Monday
Monday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Tuesday
Tuesday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Wednesday
Wednesday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Thursday
from ______ AM/PM to ______ AM/PM $_______
Thursday
from ______ AM/PM to ______ AM/PM $_______
Friday
from ______ AM/PM to ______ AM/PM $_______
Friday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Saturday
Saturday
from ______ AM/PM to ______ AM/PM $_______
from ______ AM/PM to ______ AM/PM $_______
Sunday
Sunday
TOTAL NUMBER OF HOURS, WEEK THREE: ____________
TOTAL NUMBER OF HOURS, WEEK FOUR: ______________
TOTAL INCOME EARNED, WEEK THREE:______________
TOTAL INCOME EARNED, WEEK FOUR:________________
TOTAL NUMBER OF CUSTOMERS SERVED:_____________
TOTAL NUMBER OF CUSTOMERS SERVED:_____________
**Name and phone number of customers served this
**Name and phone number of customers served this
week must be on receipts or invoices:
week must be on receipts or invoices:
The information written on this form is true and accurate to the best of my knowledge. I am aware that
if I have given false information intentionally, I may be subject to prosecution for fraud.
x
X__________________________________________________
_________________________________
Date
Parent/Guardian Signature
Verification of Self Employment- rev. 5/10/2016
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