Basic Statement of Self-Employment Income & Expense Form

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 Receipts
Gross Receipts is the income you receive from your business. You should retain supporting documents that total the amounts and sources of your Gross Receipts.
Advertising
Legal and Professional Services
Contract Labor
Repairs/Maintenance
Office Expenses
Rent/Lease Property
Meals and Equipment
Supplies
Health Insurance
Commission/Fees
Utilities
Other Interest
Taxes/Licenses
Travel
Other Expenses
Employee Wages
Description of Vehicle (business use)
Date Vehicle Placed in Service
Commuting Miles (miles commuting to the office or first stop of the day)
Other Miles
Off Duty Miles (any personal miles)
Do you have another vehicle available for personal use?
Do you have a home office?
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 all the information provided is true, correct, and complete to the best of my ability, knowledge and belief.
Signature
Date

MonthDayYear
Date
File Upload

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