Form HW0506 "Self-employment Verification Report (LLC, S-Corp, or Partnership)" - Idaho

What Is Form HW0506?

This is a legal form that was released by the Idaho Department of Health and Welfare - a government authority operating within Idaho. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 1, 2011;
  • The latest edition provided by the Idaho Department of Health and Welfare;
  • Easy to use and ready to print;
  • Available in Spanish;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form HW0506 by clicking the link below or browse more documents and templates provided by the Idaho Department of Health and Welfare.

ADVERTISEMENT
ADVERTISEMENT

Download Form HW0506 "Self-employment Verification Report (LLC, S-Corp, or Partnership)" - Idaho

Download PDF

Fill PDF online

Rate (4 / 5) 7 votes
Self-Employment Verification Report
LLC, S-Corp, or Partnership
HW0506 | Rev 09/2011
Case Name:
Case Number:
Participant Name
Social Security Number:
(If different than Case Name):
Business Name:
Business Address:
Business Phone:
Type of Business:
If yes, how many months has the
Was this business started
Income Months:
Yes
No
business been in operation?
within the last year?
(e.g., 01/07-06/07)
Instructions: Complete the following sections to verify your self-employment information for the tax year or number of months your
business was in operation (recorded above). The information you provide is used by the Idaho Department of Health and Welfare (IDHW)
to calculate self-employment income and deductions according to IDHW regulations.
Part I: Income
1.
Gross Receipts or Sales
+
2.
Net Profit from Sale of Assets (Capital Gains)
Total Part I:
$
(add line 1 and 2)
3.
Part II: Cost of Goods Sold
Cost of Goods Sold is the amount expended to produce or manufacture merchandise sold, including material and labor used to produce
products for sale and products purchased for resale (less ending inventory of items not sold), during the tax year or number of months the
business was in operation (recorded above).
$
Total Part II:
4.
Cost of Goods Sold
Part III: Gross Income
5.
Total of Part I (line 3)
-
6.
Total of Part II (line 4)
Total Gross Income:
$
(subtract line 6 from line 5)
7.
If you receive wages from the S-Corp, LLC, or Partnership, attach all wage stubs received during the timeframe you indicated
in the Income Months box above.
Page 1 of 2
Self-Employment Verification Report
LLC, S-Corp, or Partnership
HW0506 | Rev 09/2011
Case Name:
Case Number:
Participant Name
Social Security Number:
(If different than Case Name):
Business Name:
Business Address:
Business Phone:
Type of Business:
If yes, how many months has the
Was this business started
Income Months:
Yes
No
business been in operation?
within the last year?
(e.g., 01/07-06/07)
Instructions: Complete the following sections to verify your self-employment information for the tax year or number of months your
business was in operation (recorded above). The information you provide is used by the Idaho Department of Health and Welfare (IDHW)
to calculate self-employment income and deductions according to IDHW regulations.
Part I: Income
1.
Gross Receipts or Sales
+
2.
Net Profit from Sale of Assets (Capital Gains)
Total Part I:
$
(add line 1 and 2)
3.
Part II: Cost of Goods Sold
Cost of Goods Sold is the amount expended to produce or manufacture merchandise sold, including material and labor used to produce
products for sale and products purchased for resale (less ending inventory of items not sold), during the tax year or number of months the
business was in operation (recorded above).
$
Total Part II:
4.
Cost of Goods Sold
Part III: Gross Income
5.
Total of Part I (line 3)
-
6.
Total of Part II (line 4)
Total Gross Income:
$
(subtract line 6 from line 5)
7.
If you receive wages from the S-Corp, LLC, or Partnership, attach all wage stubs received during the timeframe you indicated
in the Income Months box above.
Page 1 of 2
Instructions: Complete the following section to verify your self-employment expenses for the tax year or number of months your business
was in operation (recorded on page 1 of this form).
Part IV: Expenses
8.
Advertising
9.
Chemicals
10. Contract Labor/Labor
/ Customer Hire
(non-household members)
11. Feed
12. Fertilizers
13. Freight/Trucking
14. Insurance/Worker's Compensation
15. Interest on Business Loans
16. Legal/Professional Services
17. Materials/Goods/Supplies
18. Office Expenses
19. Rent/Tax on Business Property
20. Repairs and Maintenance
21. Seeds/Plants
22. Tax and License Fees
23. Utilities/Phone
24. Vehicle Expense/Mileage
(not to and from home)
25. Veterinary
26. Other
(please indicate the type of expense)
27. Other
(please indicate the type of expense)
28. Other
(please indicate the type of expense)
$
Total Part IV:
29.
Part V: Countable Income (based on actual expenses)
30. Total of Part III – Gross Income (line 7)
31. Total of Part IV - Expenses (line 29)
32. Subtract line 31 from line 30
.
33. Percent of business you own (write in decimal form, e.g. 45% = .45)
34. Multiply line 32 by line 33
35. Divide line 34 by the number of income months (indicated on page 1)
Total Net Income:
$
(subtract line 31 from line 30)
36.
Signature
Under penalty of perjury, I swear or affirm the information I have reported is true and complete.
Signature of applicant/authorized representative
Phone
Date
Page 2 of 2
HW0506 | Rev 09/2011
Page of 2