Self Employment Earnings Form - State Of Hawaii Department Of Human Services
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1State of Hawaii
Benefit Employment & Support Services Division
Department of Human Services
Low Income Home Energy Assistance Program (LIHEAP)
SELF EMPLOYMENT EARNINGS
NAME: _____________________________________________
DATE: ___________________
COMPANY NAME: ______________________________________________
NATURE OF BUSINESS: ________________________________________
________________________________________________________________________________
ANSWER THE FOLLOWING QUESTIONS BY PLACING AN “X’ IN THE ‘YES’ OR ‘NO’ BLOCK AFTER THE QUESTION. BASED ON YOUR
RESPONSES A DECISION WILL BE MAKE WHETHER YOU MEET THE CONDITIONS OF A SELF-EMPLOYED PERSON:
YES
NO
1.
I sell a service or product for a profit.
☐
☐
2.
I am independently responsible for obtaining or providing
☐
☐
providing a service or product.
3.
I have independent costs and expenses to provide a service
☐
☐
or product.
4.
I independently determine the manner, method and process
☐
☐
of the business, which affects its success or failure.
5.
I paid a General Excise License Fee.
☐
☐
6.
I pay employer and employee’s share of Social Security Taxes
☐
☐
as a self-employed person.(
Answer only if you have employees)
7.
I have a valid current State of Hawaii General Excise Tax License. ☐
☐
EXPENSES
INCOME
FOR AGENCY USE ONLY
(HOW VERIFIED)
GROSS SELF-EMPLOYMENT INCOME
$ ________________
BUSINESS EXPENSES:
NOTE: DO NOT LIST PERSONAL EXPENSES AND TAXES
(I.E. SELF-EMPLOYMENT, SOCIAL SECURITY, FEDERAL,
STATE) THAT YOU PAY. HOWEVER, IF YOU HAVE
EMPLOYEES, LIST THE SALARY, TYPES AND AMOUNTS OF
TAXES THAT YOU PAY ON THEIR BEHALF IN THIS SECTION.
(YOU CANNOT BE AN EMPLOYEE OF YOUR OWN
BUSINESS).
GENERAL EXCISE TAX LICENSE FEE
$ _____________
GENERAL EXCISE TAX
$ _____________
(% OF INCOME)
OTHER (LIST BUSINESS EXPENSES)
$ _____________
$ _____________
$ _____________
Expenses Verified By:
$ _____________
$ _____________
TOTAL EXPENSES
$_______________
NET EARNED INCOME
$ ______________
______________________________________________
________________________
(SIGNATURE OF SELF EMPLOYED PERSON)
(DATE)
L-12
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