Free Self-Employment Income Report, F-00107 - Wisconsin

WISCONSIN DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-00107 (07/09)

SEI

SELF­EMPLOYMENT INCOME REPORT
Personally identifiable information will only be used for the direct administration of assistance programs.* Month of Report (month/year) Today's Date Worker Name Agency Name (Last, First, MI) Home Address Business Name City Case Number (if known) State Zip Code

Business Address (if not your home address) (Street, City, State, Zip Code)

INCOME AND EXPENSES ­ Enter the amount for the previous month. Keep records, such as receipts, etc that list the amounts you enter. For partnerships and corporations, report income and expenses for the operation as a whole; your share will be calculated later.
What percent of the business is owned by the applicant(s) listed above? % Income 1. Gross receipts or sales, net capital gains and other incomes Expenses 2. 3. 4. 5. 6. 7. 8. 9. Materials and supplies (including office supplies) Wages (not including wages to yourself) Commissions paid to your employees Vehicle expenses (gas and maintenance) Travel expenses for business away from home (meals, lodging, transportation other than claimed in the car and truck category in line 5.) Rent on business property Repairs on business equipment and property (Do not include vehicle costs as this will be entered on line 5.) Business telephone and utility expenses
$ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $ $

(Used to determine if Number of hours worked this month: rental income is earned or unearned and for voluntary FSET enrollment.)

10. Freight or shipping expenses 11. Legal and professional services 12. Business insurance 13. Bank service charges to business. 14. Interest charged to business debt? (Do not include interest paid on rental property as this will be entered on line 18.) 15. Advertising expenses 16. Dues and publications 17. Other expenses (not including depreciation, transportation to and from work, purchase of capital equipment or payment on the principle of loans for capital assets or durable goods.) a) b) c) 18. Interest payments on loans for the purchase price of income producing real estate, capital assets and equipment, and durable goods. . Principal payments on loans for the purchase price of income producing real estate, capital assets and 19 equipment, and durable goods. . Depreciation 20

$ 21. TOTAL EXPENSES (Add lines 2 through 20 and enter the amount.) $ 22. NET BUSINESS INCOME (or loss) (Subtract line 21 from line 1 and enter the amount.) I hereby certify that the information given is accurate to the best of my knowledge. I understand that I may be required to present records and documents to support the figures given.

Participant Signature
Privacy Law, s. 15.04(1)(m), Wisconsin Statutes

Date Signed PAGE 1

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SELF-EMPLOYMENT INCOME REPORT F-00107 (07/09)

SEI

For Office Use Only: This page is to be completed by the Income Maintenance worker to compare against the applicable AG Budget outcome(s) for this business after self-employment entry into CWW. FoodShare (FS) Countable Income: 1. Net Business Income (Line 22 of page 1) 2. Depreciation (Line 20 of page 1) If negative, enter zero. 3. Countable Income (Line 1 plus line 2 above) 4. If ownership of corporation or partnership is less than 100%, multiply line 3 above by % of business owned by AG.

$ + $ = $ Complete this step only if applicable: Total from Line 3 above: $ X % ownership: X % = FS Countable Income: $

Medicaid for the Elderly, Blind or Disabled (MA) Countable Income: 1. Net Business Income (Line 22 of page 1) 2. Disallowed expense of principal payments on loans for the purchase price of income producing real estate, capital assets and equipment, and durable goods (Line 19 of page 1) 3. Countable Income (Add lines 1 and 2 above). 4. If ownership of corporation or partnership is less than 100%, multiply line 3 above by % of business owned by AG. $ + $

= $ Complete this step only if applicable: Total from Line 3 above: $ X % ownership: X = MA Countable Income: $

%

BadgerCare Plus (BC+) Countable Income: 1. Net Business Income (Line 22 of page 1) 2. Disallowed expense of principal payments on loans for the purchase price of income producing real estate, capital assets and equipment, and durable goods (Line 19 of page 1) 3. Depreciation (Line 20 of page 1) If negative, enter zero. 4. Countable Income (Add lines 1, 2, and 3 above). 5. If ownership of corporation or partnership is less than 100%, multiply line 4 above by % of business owned by AG. $ + $

+ $ = $ Complete this step only if applicable: Total from Line 4 above: $ X % ownership: X % =BC+ Countable Income: $ Note: If applicable, 2nd income test using IM income without depreciation added back into the income will appear as follows: Total of Line 4 above (or 5 if applicable): $ Less Depreciation Expense* (Line 3 above): - $ BC+ 2nd Income Test Outcome: = $

*Multiply by percent ownership if less than 100% of business is owned by AG.

Note: When using multiple months of SEIRFs to calculate average, enter the average of all SEIRFs completed by the member for this business when completing lines on this page of worksheet. This page only needs to be completed once to calculate the average of all SEIRFs completed by a member for a business.

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