Statement of Self-Employment

Statement of Self-Employment
I certify that I am self-employed.
First and Last Name*

First NameLast Name
I make a monthly average of *
My average monthly business expenses are (note: only list tax deductible expenses. DHS may request proof of these expenses) *
You can put zero if it is zero
I have been self employed since*

MonthDayYear
Did you meet the income threshold to file taxes on this self-employment income last year?*
Note: There is no need to file if you're under the self-employment filing threshold.
I am signing this under penalty of perjury which means I have provided true answers to all the questions on this form to the best of my knowledge. I know that I may be subject to penalties under federal law if I provide false or untrue information I know that I must tell the Department of Human Services (DHS) if anything changes (and is different than) what I declared on my application. I can visit access.arkansas.gov or call 1-855-372-1084 to report changes. I understand that a change in my information could affect the eligibility for members of my household
Address*

Address

Street Address Line 2

CityState

Zip
The type of work I do is:*
Social Security Number*
Confirm Social Security Number*
Date of Birth*

MonthDayYear
Date
Signature*

Powered by Jotform SignClear
Email
example@example.com
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: