Self-Employment Certification

Self-Employment Certification
Self-Employment

Business #1
Business Name
Profession Type
Business Description
Date Business Started

MonthDayYear
Date
EIN
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Email
example@example.com
Website
Do you have a business license or certification?

YesNo
Has your business taken a (loss) in profits in the past three years?

YesNoUnsure
Income
Accounting Method

CashAccrualOther
Do you file state or local sales tax returns for the year?

YesNoNot applicable
Do you receive Forms 1099-MISC, 1099-NEX or 1099-K for the income reported?

YesNo
How do you track your income?

Accounting records (e.g. QuickBooks, Sage, Peachtree)Business/Personal bank account statements with business income highlightedElectronic payment records (e.g. Apple Pay, PayPal, Zelle, Cash App, Venmo)Invoices/Receipts issued to customers for goods and servicesLogbooks/Ledgers1099-MISC1099-NEC1099-KOther
Do you have a completed Profit & Loss Statement?

YesNo
Expenses
How do you track your expenses?

Accounting records (e.g. QuickBooks, Sage, Peachtree)Business/Personal bank account statements with business income highlightedElectronic payment records (e.g. Apple Pay, PayPal, Zelle, Cash App, Venmo)Invoices/Receipts issued to customers for goods and servicesLogbooks/LedgersOther
Do you use one or more vehicles for your business?

YesNo
Do you utilize any parts of your home to operate your business?

YesNo
Does your business produce income by manufacturing, selling or purchasing goods?

YesNoUnsure
List the total amounts spent for each category for your business in 2022.
Advertising
Car & Truck expenses (e.g. Repairs, maintenance, tolls, tickets, insurance, inspection, etc.)
Cell phone
Commissions & Fees
Contract Labor
Employee Benefits Program
Insurance (Other than health)
Interest (Mortgage)
Interest (Other)
Legal & Professional Services
Office Expenses
Pension & Profit-sharing Plans
Rent/Lease (Vehicle, machinery, equipment)
Rent/Lease (All other business property)
Repairs & Maintenance
Supplies
Taxes & Licenses
Travel
Travel (Deductible Meals)
Utilities
Wages (less employment credits)
Other Expenses (Description, Amount)
Vehicle

Vehicle #1
When did you place your vehicle in service for business purposes?

MonthDayYear
Date
Detail the use of your vehicle for your business:
Of the total number of miles you drove your vehicle during 2022, enter the number of miles you used your vehicle for:
Business
Commuting
Other
Was your vehicle available for personal use during off-duty hours?

YesNo
Do you (or your spouse) have another vehicle available for personal use?

YesNo
Do you have written evidence to support your vehicle mileage?

YesNo
Home
Detail the use of your home for your business:
What amount of square footage of your home is used for business?
What the total square footage of your home?
Utility Expenses (Total Paid)
Electricity
Internet
Water
Natural Gas
Other expenses (Description, amount)
Cost of Goods
Methods used to value inventory?

CostLower of cost of marketOther
Was there any change in determining quantities, costs, or valuations between opening and closing inventory?

YesNoOther
If yes, explain:
Cost of all merchandise for the year
Cost of labor (not amounts paid to self)
Materials & supplies
Other costs
Inventory at beginning of year
Inventory at end of year
Business Documentation
Upload supporting documents (e.g. 1099s, Profit & Loss Statement or Accounting documentation, Receipts, Mileage Log, etc.)

Cancelof
I delcare that this information is true and accurate. I understand that I may be prosecuted for fraud and perjury under the state statutes if I knowingy provide false information. In order to comply with federal due diligence regulations, tax payers may reasonably reconstruct a taypayer's income and expenses for the year. By signing and checking the box below, I agree that the information is neither inconsistant, incorrect, and incomplete.

I am also certifying that I am a self-employed individual and I am aware that a Schedule C is being completed by the tax preparer with my permission and with my knowledge.
I agree

I agree
Business Owner (Taxpayer or Spouse)

Powered by Jotform SignClear
Name

First NameLast Name
Date

MonthDayYear
Date
Should be Empty:

Self-Employment Certification

Self-Employment

Income

Expenses

Vehicle

Home

Utility Expenses (Total Paid)

Cost of Goods

Business Documentation