EOAC Self Employment Form

STATEMENT OF SELF-EMPLOYMENT INCOME

DECLARACION DE INGRESOS DEL NEGOCIO PROPIO

This form must accompany the Declaration of Income Statement.

Este Forma debe acompanyar la Declaración de Ingresos del Negocio Propio.

1. Name of Person having Self-Employment Income:

Nombre de la persona que tiene ingresos de negocio propio:

2. Describe the type of work and include any and all tips, for the last 30 days including today.

Describe el tipo del trabajo y los ingresos de su negocio, incluyen consejos de todos y, para los últimos 30 días incluyendo hoy.

Name of Person with Self Employment Income*

First NameLast Name

Applicant Name (Head of Household listed on application - if different than person with self employment income)

First NameLast Name

Please list self employment income:*

	Date	Describe what you did to earn this money	Amount
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15

Total Self Employment Income for Month (30 Days)*

The above information is true, correct, and complete to the best of my knowledge. I understand that giving false information could result in my being disqualified for fraud.

Segun mi leal saber y entender, toda esta informacion es cierta, correcta y completa. Comprendo que se doy informacion falsa puedo ser discalifaco por fraude.

Signature/Firma*

Date/Fecha*

Date