Fillable TANF MEDICAID SNAP SELF-EMPLOYED/TIP STATEMENT EARNED INCOME STATEMENT (State of Nevada, Department of Information Technology)

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TANF MEDICAID SNAP SELF-EMPLOYED/TIP STATEMENT EARNED INCOME STATEMENT (State of Nevada, Department of Information Technology)

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STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
STEVE SISOLAK
Governor
RICHARD WHITLEY, MS
Director
STEVE H. FISHER
Administrator
TANF MEDICAID SNAP
Date:
Case Name:
Case ID:
SELF-EMPLOYED/TIP STATEMENT
EARNED INCOME STATEMENT FOR
2120 - EG (210.0.0)
Page 1 of 1
Month, Year
This report should be a daily record kept of all income and expenses for your business, as required by the federal government for IRS
and Social Security (your records and receipts may be requested to verify this report).
DATE
1st
INCOME TIPS EXPENSE
# OF
HOURS
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
DATE
16th
INCOME TIPS EXPENSE
# OF
HOURS
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
I received a total income of
$
I worked a total of hours. My total expenses were
$
.
/ /
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TANF MEDICAID SNAP SELF-EMPLOYEDTIP STATEMENT EARNED INCOME STATEMENT (State of Nevada, Department of Information Technology)

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Completed 28 September 2020

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