Self-Employment Income Fillable PDF - Quinault Indian Nation

Please note that receipts must be attached for reported expenses to be factored into net income calculation. Reported expenses must be for business items/services that you paid for. Items/services that were paid for by someone else cannot be considered. To ensure that your Monthly Eligibility Report (MER) is deemed complete, this form (and applicable receipts) must be submitted with the MER by the given deadline.

Name(Required)

First Middle Last Suffix

Monthly Amount Earned(Required)

$$$

Amount Earned Month(Required)

Write out full month: January, February, March

Type of Self Employment(Required)

Ex: Plumbing, Landscaping, Jewelry fabrication, household cleaning.

My self-employment related expenses for the month are listed below:

Expense

Amount

Expense

Amount

Expense

Amount

Expense

Amount

Expense

Amount

Expense

Amount

Expense

Amount

Expense

Amount

Total Expense Amount(Required)

Net Income Calculation(Required)

Participant Signature(Required)

I attest that all of the information that I have provided is true and correct to the best of my knowledge. I understand that failure to report or any misrepresentation of your true earnings and expenses will be considered fraud.

Date(Required)

In order to protect your private information the completed PDF form will be encrypted with a password. Please type a memorable password below.

Password(Required)

The completed PDF form will be emailed to you please provide an email address below.

Email(Required)