I* AM SELF EMPLOYED. THE INCOME AND EXPENSES I REPORTED ARE TRUE AND CORRECT. I HAVE PROVIDED VALID DOCUMENTS TO SUPPORT THE INCOME AND EXPENSES REPORTED ON MY 2022 FEDERAL TAX RETURN, INCLUDING SCHEDULE C.

Tax Payer Summary of Income: *
Tax Payer summary expenses:   *   
Print Name:   *   
Signature:   Signature*      
Date:   Date*      

BUSINESS OF PROFESSION: * BUSINESS NAME:
BUSINESS ADDRESS, CITY, STATE, ZIP:   Street Address*      City*   State*   Zip*      
EMPLOYER ID #:      

Are you the owner of a business?    Yes    No*  

 Is the business a Partnership?    Yes    No  

 Is the business a D.B.A?    Yes    No   

Is the business a corporation?    Yes    No   

Did you use a log book to determine your log receipts?    Yes    No*   

If you did NOT use a log book, can you reasonably reconstruct your gross receipts?    Yes    No   

Did you use a log book to determine your expenses?    Yes    No   

If you did NOT use a log book, can you reasonably reconstruct your expenses?  
  Yes    No   

How were you paid? (Check All That apply) Cash    Check    Other   

Did you receive a form 1099-MISC, box 7 income?    Yes    No   

What are you using the vehicle for in your business? *

When did you place your vehicle in your service for business purposes?   Date

Which method are you using this year? Standard Mileage Rate      
Actual Expenses   *   

Total number of miles you drove the vehicle during 2022, how many miles was the vehicle used for:

Business:      Commuting:      Other:      

Do you have written evidence to support your deduction?    Yes    No