Free SELF-EMPLOYMENT INCOME WORKSHEET - Sole Proprietor Farm and Other Business - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16037 (05/09)

State of Wisconsin 7 CFR 273.11 (a)(2)

SELF-EMPLOYMENT INCOME WORKSHEET - Sole Proprietor Farm and Other Business
Tax Year Filing Case Name Worker Name Case Number Worker ID Date Completed

For FARM SELF-EMPLOYMENT, begin with Section I (use Schedule F, Form 1040) For OTHER SELF-EMPLOYMENT, skip Section I and begin with Section II. Section I: INCOME FROM FARM OPERATIONS From Schedule F, IRS Form 1040 from line 36 from line 16 As specified on line 34a-f ( add (1), (2), and (3) ) (1) $

(1) Enter net profit or loss (2) Add depreciation back in (Enter zero if negative.) (3) Add amortization back in (Enter zero if negative.) (4) Equals IM-Income from farm operations

(2) + $ (3) + $ (4) = $

Section II: INCOME FROM OTHER SELF-EMPLOYMENT OPERATIONS.* If there is self-employment income other than farm, complete Section II. If not, go on to Section III. (1) Enter net profit or loss (2) Add depletion back in (Enter zero if negative.) (3) Add depreciation back in (Enter zero if negative.) (4) Add amortization back in (Enter zero if negative.) (5) Add at risk loss deduction (Enter zero if negative.) (6) Equals IM-Income from other self-employment operations ( add Section II (1) through (5) )

From Schedule C, IRS Form 1040

from line 31 from line 12 from line 13 if specified on line 27 if specified on line 27

(1)

$

(2) + $ (3) + $ (4) + $ (5) + $ (6) = $

Section III: CAPITAL AND ORDINARY GAINS If there are capital or ordinary gains or losses, complete Section III. If not, go to Section IV. (1) Enter long-term capital gain (do not enter loss)* (2) Add ordinary gain, OR subtract ordinary loss

From IRS Form 4797 from line 7 (only if gain) from line 17 or 18b

(1)

$

(2) + $

(3) Equals total sole-proprietary gain or (loss)

(add (1) and (2) )

(3) = $

* Losses should be indicated on the tax form by enclosing the amount in parentheses [e.g., ($100.00) indicates a $100 loss rather than a gain.] MORE
RETAIN COMPLETED WORKSHEET IN CASE RECORD

SELF-EMPLOYMENT INCOME WORKSHEET - Sole Proprietor Farm and Other Business F 16037 (Rev. 04/09)

Page 2

Section IV: RENTAL AND ROYALTY INCOME (unearned income) If there is any rental or royalty income, complete Section IV. If not, go to Section V. (1) Enter total rental and royalty income (2) Add depreciation and depletion back in (Enter zero if negative.) (3) Equals IM-Income rental and royalties (4) Subtract any amount identified as unearned* (5) Equals earned IM-Income from rental income ( add (1) and (2)) (enter unearned amount) ( add (3) and (4) )

From Schedule E, IRS Form 1040 From line 26 From line 20 (1) $ (2) + $ (3) = $ (4) - $ (5) = $

Section V: TOTAL INCOMES FROM ABOVE To total incomes from above, complete Section V using results from Section I through Section IV.

(1) Enter IM-Income from farm operations (2) Add IM-Income from other self-employment operations or subtract (loss) (3) Add total sole proprietary gains or subtract (loss) (4) Add earned IM-Income from rental or subtract (loss)

from Section I line (4) from Section II line (6) from Section III line (3) from Section IV line (5)

(1)

$

(2) + $ (3) + $ (4) + $

(5) Equals total sole-proprietary earned IM-Income

(add (1) through (4))

(5) = $

(6) Divide line (5) by the number of months in operation to get the monthly average.

(6) = $

* All royalty income is unearned. Rental income is also unearned when the participant works less than 20 hours per week on average. The worker must ask the customer about income on Schedule E (Form 1040) to make this determination. Any unearned income [shown on Section IV, line (4)] must be entered as such on the combined application form. If the participant works 20 or more hours per week earning rental income use Schedule C to calculate self-employment earned income.

NOTE: THE TOTAL IM-INCOME RECORDED HERE ON Section V, LINE (5), [and/or Section IV, line (4)], MUST BE DIVIDED BY THE NUMBER OF MONTHS THE BUSINESS WAS "IN OPERATION" TO ARRIVE AT THE MONTHLY AVERAGE.

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