RENTAL ASSISTANCE FOR MISSISSIPPIANS
EMERGENCY RENTAL ASSISTANCE (ERA) PROGRAM
SELF-EMPLOYMENT INCOME FORM
Self-employed applicants should provide, (i) if their income determination for this program is based on
2020 annual income, a copy of their 2020 tax return, or, (ii) if their income determination for this
program is based on income for the last sixty (60) days, copies of bank statements demonstrating
regular income. If an applicant cannot provide one of the foregoing types of documentation, then the
applicant should complete this Self-Employment Income Form.
By completing and submitting this Self-Employment Income Form, I certify that I cannot provide one of
the foregoing types of documentation to verify my income.
Name of Self-Employed Applicant:
Business Name (if applicable):
Business Address:
Describe the nature of your business and how it generates revenue (be specific):
Self-Employment Income Calculation:
Time Period used for Income Calculation (MM/DD/YY – MM/DD/YY):
Total Business Revenue:
Total Business Expenses:
Total Self-Employed Income (subtract business expenses from business revenue):
Under penalty of perjury, I attest that the information presented in this Self-Employment Income Form
is true and accurate to the best of my knowledge. I further understand that providing false
representations constitutes an act of fraud. False, misleading, or incomplete information may result in
my obligation to repay any funds received through the Emergency Rental Assistance Program and/or
other penalties or remedies available under applicable law. I also give the Emergency Rental Assistance
Program, MHC, and their program partners permission to obtain a copy of my tax returns from the
Internal Revenue Service or Mississippi Department of Revenue and/or any other information that is
necessary and that can be acquired from any Federal or State agency in order to confirm the above.
Signature Date
