self employment declaration

BASIC STATEMENT OF SELF-EMPLOYMENT INCOME & EXPENSE FORM
Name

First NameLast Name
Business Name
EIN
Type of Business
Date

MonthDayYear
Date
TOTAL AMOUNT OF GROSS RECIEPTS
Gross Receipts are the income you receive from your business. You should retain supporting documents that show the amounts and sources of your gross receipts $
Advertising
Legal and Professional Services
Contract Labor
Repairs/Maintenance
Rent Lease Equip
Office Expenses
Rent/Lease Property
Meals and Equipment
Supplies
Health Insurance
Commission/Fees
Utilities
Other Interest
Taxes/Licenses
Travel
OTHER EXPENSES
Amount
Employee Wages
Description of Vehicle
Date Vehicle Placed in Service

MonthDayYear
Date
Commuting Miles
(miles commuting to the office or first stop of the day)
Other Miles
(any off duty personal miles)
Do you have another vehicle available for personal use? Yes

Do you have a home office? Yes
Square Footage of home office
Square footage of home
By signing below, I affirm that I have read or had this statement read to me in full and that all information I have given is true, correct, and complete to the best of my ability, knowledge, and belief.
Client Signature

Clear
Date

MonthDayYear
Date
When complete upload form into additional documentation.
File Upload

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