Scribd
Upload
826 views1 page

Self Employement Affidavit Form

This self-employment affidavit provides details about a self-employed individual's business and income. It includes the individual's name, address, and occupation. It then requests information about gross income, expenses, net income, and taxes paid over the past 12 months. The individual must sign and date the affidavit, and it must be notarized.

Uploaded by

Lucy Freeman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
826 views1 page

Self Employement Affidavit Form

This self-employment affidavit provides details about a self-employed individual's business and income. It includes the individual's name, address, and occupation. It then requests information about gross income, expenses, net income, and taxes paid over the past 12 months. The individual must sign and date the affidavit, and it must be notarized.

Uploaded by

Lucy Freeman
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

SELF-EMPLOYMENT AFFIDAVIT

I, (Name)________________________ of (Address)_________________________ state that I


am self-employed, said occupation being _________________________________________. My
place of business is located at:
__________________________________________________________.
I sign the declaration under penalty of perjury.
STATEMENT OF INCOME FROM BUSINES
Instructions:
1. Opposite GROSS INCOME insert total amount earned during the past 12 months or
shorter period.
2. Add all expenses incurred in the performance of this business and subtract the total of
these EXPENSES from the gross income.
3. Insert the result in the space NET INCOME.
A. GROSS INCOME: $_____________________ period covered by GROSS income
shown.
Beginning date: __________________ Ending date: _____________________
B. EXPENSES:
1. Cost of goods and materials $__________________
2. Rent (business location only) $__________________
3. Heat, light, water, phone, etc. (business only)$__________________
4. License fees $__________________
5. Other (specify) $__________________
6. Number of Employees_________
7. Employees salaries (other than self/family) $__________________
8. Owners salary (self/family) $__________________
C. GROSS INCOME $________________
TOTAL EXPENSES - $________________
NET INCOME: = $__________________
D. Total amount of income taxes paid as of _______________
Federal Taxes $________________
State Taxes + $________________
City Taxes + $________________
TOTAL TAXES: = $__________________

ATTACH MOST RECENT COPY OF YOUR FEDERAL TAX RETURN.


.
Signature: _______________________________________ Date: _____________________

In witness whereof, this _____________ day of _________________.

My commission expires: ___________________ (Notary Public):

You might also like