Fillable State of Georgia Rental Assistance Program Self-Employment Income (City of Oakland)

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State of Georgia Rental Assistance Program Self-Employment Income (City of Oakland)

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The State of Georgia Rental Assistance Program Self-Employment Income (City of Oakland) form is 2 pages long and contains:

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Country of origin: US
File type: PDF

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State of Georgia Rental Assistance Program
Self-Employment Income Certification
Any applicant who is self-employed should complete this form if they are submitting current income OR if
they are submitting 2020 income and have not yet filed taxes. You may submit a copy of the 2020 tax return
in place of this form.
Name of person who has self-employment income:
Company Name (if Applicable):
Company Address:
Date of Income Reported (MM/DD/YY – MM/DD/YY):
Describe what you did to earn this money (be specific): ________________________________________
Self-Employment Expenses Calculation
List your business expenses. Enter the dates you paid the expenses and amount of each expense. Add the
amounts and enter your total in the box “Total Expenses.”
IMPORTANT: Please submit receipts, invoices, or other verifying papers in addition to this form.
Date/Date Range
Expenses
Amount
Total Expenses =
Self-Employment Income Calculation
List the dates you received the income, your sources of income, and the amounts. Add the
amounts and enter your total in the box “Total Income.” Under the “Total Income” box,
enter your total expenses. Subtract your total expenses from the total income and enter
your “Net Self-Employment Income.”
IMPORTANT: Please submit receipts, invoices, or other verifying papers in addition to this form.
Date
Income Source
Amount
Total Income =
Subtract Expenses =
Net Self Employment Income =
In signing this certification (including electronic signature) you are acknowledging that
falsification of documents or any material falsehoods or omissions in the Application,
including knowingly seeking duplicative benefits, is subject to state and federal criminal
penalties. You are particularly put on notice that 18 U.S.C. §1001 provides, among other
things, that whoever knowingly and willingly makes or uses a document or writing
containing any false, fictitious, or fraudulent statement or entry, in any matter within the
jurisdiction of any department or agency of the United States will be fined not more than
$10,000 or imprisoned for not more than five years, or both.
Signature Date
Signature of Person Helping Complete Form Date
(if Applicable)
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State of Georgia Rental Assistance Program Self-Employment Income (City of Oakland)

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Completed 12 March 2021

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