If you do complete this form, your DHS office will be better able to determine your eligibility for benefits Business Income Source Date Received Gross Income
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State of Illinois
Department of Human Services
SELF-EMPLOYMENT RECORD
7 (PERMANENT)
IL 444-2790 (R-5-04)
Page 1 of 2
Client Name:
This self-employment income is for the period ofthroughBecause you are self-employed, you are required to report all of your em�ployment income and employment expenses to the
Department of Human Services. This information is to be supplied with y�our EI REDE application. In order to determine your
eligibility for assistance, you must provide us with accurate and compl�ete records of money you take in and the work expenses
you pay out. To do this you must write down all money you take in and i�ts source. You must also write down any expenses you
had in producing your income. Be sure to include all transactions which occurred during your reportin�g period. Also,
save your receipts.Expenses of producing income include but are not limited to things like �inventory, materials, services, transportation, employee
salaries, and loan payments. You may choose what month you want to clai�m an expense, but you cannot claim the expense
more than once. You may only claim the percentage of the vehicle costs �equal to the percentage of mileage that the vehicle is
used for business purposes. Depreciation, charitable contributions, ent�ertainment, and personal expenses are NOT allowable
business expenses.If you wish, you may use this form to keep your records. You are not re�quired to complete this form, but you are required to
keep accurate records of your self-employment income and expenses. The Department will need a copy of the record you
choose to use. If you do complete this form, your DHS office will be better able to de�termine your eligibility for benefits.
Business Income Source Date Received Gross Income Business Expenses Expense/ItemPurchased/ Paid to Whom Amount
Client Number:
Caseload Number:
Address:
State of Illinois
Department of Human Services
SELF-EMPLOYMENT RECORD
7 (PERMANENT)
IL 444-2790 (R-5-04)
Page 2 of 2
Business Income Source Date Received Gross Income Business Expenses Expense/ItemPurchased/ Paid to Whom Amount
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