Fillable TANF MEDICAID SNAP SELF-EMPLOYMENT WORKSHEET If a member (State of Nevada, Department of Information Technology)

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TANF MEDICAID SNAP SELF-EMPLOYMENT WORKSHEET If a member (State of Nevada, Department of Information Technology)

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BROWSE STATE OF NEVADA, DEPARTMENT OF INFORMATION TECHNOLOGY (NV) FORMS

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SELF-EMPLOYMENT WORKSHEET
STATE OF NEVADA
DEPARTMENT OF HEALTH AND HUMAN SERVICES
RICHARD WHITLEY, MS
DIVISION OF WELFARE AND SUPPORTIVE SERVICES
Director
STEVE H. FISHER
Administrator
STEVE SISOLAK
Governor
2011 - EG (213.0.0)
Page 1 of 2
TANF MEDICAID SNAP
Date:
Case Name:
Case ID:
If a member of the household receives income from self-employment, other than farming, complete the following information
for the report period of
through
.
Business Name: Address:
Owner’s Name: Address:
Period of Operations: through
1 Gross receipts or sales (include 100% of capital gains)
$
2 Inventory at beginning of period
$
3 Merchandise Purchased
$
4 Cost of Labor (exclude your wages)
$
5 Raw Materials and Supplies
$
6 Add lines 2 through 5
$
7 Inventory at end of period
$
8 Subtract item 7 from item 6. This is your COSTS OF GOODS SOLD
$
9 Taxes and Assessments on Business Property
$
10 Rent Paid on Business Property or Equipment
$
11 Legal and Professional Fees
$
12 Operating Supplies
$
13 Repairs (not including capital improvements)
$
14 Interest on purchase of business equipment
$
15 Advertising
$
16 Interest (on income-producing property)
$
17 Utilities
$
18 Postage and Publications
$
19 Telephone
$
20 Insurance
$
21 Transportation
$
2011 - EG (213.0.0)
Page 2 of 2
22 Commission Paid
$
23 Other(describe)
$
24 Combine items 11-23. These are your OTHER BUSINESS EXPENSES
$
25 Add lines 8, 9, 10 and 24 for your TOTAL COSTS OF BUSINESS
$
26 Subtract item 25 from item 1. This is your NET INCOME
$
PROVIDE VERIFICATION OF ALL INCOME REPORTED ON LINE 1 AND COPIES OF ALL EXPENSE RECEIPTS. IF YOU HAVE
CLIENTELE, PROVIDE ON SEPARATE SHEET NAMES, ADDRESSES AND PHONE NUMBERS.
I declare the information given on this form is true and complete to the best of my knowledge. I am also aware the following are
NOT considered business expenses: depreciation; personal expenses such as federal, state and local income tax payments;
lunches; entertainment expenses; personal transportation (i.e., to and from work); purchase of capital equipment; and
payments on the principal of loans for capital assets or durable goods.
/ /
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TANF MEDICAID SNAP SELF-EMPLOYMENT WORKSHEET If a member (State of Nevada, Department of Information Technology)

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Completed 28 September 2020

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