[{"data":1,"prerenderedAt":-1},["ShallowReactive",2],{"detail-sidebar-cat-1-en-105":3,"doc-seo-280933-105":53,"doc-detail-280933-en":130},{"code":4,"msg":5,"data":6},0,"success",[7,14,19,24,29,34,39,44,49],{"id":8,"doc_module":9,"doc_module_name":10,"category_name":11,"show_sort_weight":12,"slug":13},11,1,"Template","Presentations",90,"presentations",{"id":15,"doc_module":9,"doc_module_name":10,"category_name":16,"show_sort_weight":17,"slug":18},12,"Resumes",80,"resumes",{"id":20,"doc_module":9,"doc_module_name":10,"category_name":21,"show_sort_weight":22,"slug":23},14,"Invoices",70,"invoices",{"id":25,"doc_module":9,"doc_module_name":10,"category_name":26,"show_sort_weight":27,"slug":28},15,"Posters",60,"posters",{"id":30,"doc_module":9,"doc_module_name":10,"category_name":31,"show_sort_weight":32,"slug":33},16,"Social Media",50,"social-media",{"id":35,"doc_module":9,"doc_module_name":10,"category_name":36,"show_sort_weight":37,"slug":38},17,"Forms",40,"forms",{"id":40,"doc_module":9,"doc_module_name":10,"category_name":41,"show_sort_weight":42,"slug":43},18,"Letters",30,"letters",{"id":45,"doc_module":9,"doc_module_name":10,"category_name":46,"show_sort_weight":47,"slug":48},21,"Paper Templates",5,"papers-templates",{"id":50,"doc_module":9,"doc_module_name":10,"category_name":51,"show_sort_weight":4,"slug":52},158,"General","general-158",{"code":4,"msg":54,"data":55},"ok",{"site_id":56,"language":57,"slug":58,"title":59,"keywords":60,"description":61,"schema_data":62,"social_meta":123,"head_meta":125,"extra_data":127,"updated_unix":129},105,"en","income-verification-form-self-employment-proof-of-monthly-income","Income Verification Form (Self-Employment) - Proof of Monthly Income","","Verification of Self-Employment Income form used to document net monthly income for self-employed individuals and gig workers without formal bookkeeping. The form collects household member details, reference ID, contact information, and a business-by-business income summary including gross income, monthly expenses, net monthly income, and total annual net amounts. It also requests deductible business expenses, notes any seasonal variance, and includes a perjury certification with signature, date, and submission instructions for health coverage processing.",{"@graph":63,"@context":122},[64,80,101],{"@type":65,"itemListElement":66},"BreadcrumbList",[67,71,74,77],{"item":68,"name":69,"@type":70,"position":9},"https://docshare.wps.com","Home","ListItem",{"item":72,"name":10,"@type":70,"position":73},"https://docshare.wps.com/template/",2,{"item":75,"name":36,"@type":70,"position":76},"https://docshare.wps.com/template/forms/",3,{"item":78,"name":59,"@type":70,"position":79},"https://docshare.wps.com/template/income-verification-form-self-employment-proof-of-monthly-income/280933/",4,{"url":78,"name":59,"@type":81,"image":82,"author":87,"headline":59,"publisher":90,"fileFormat":93,"inLanguage":57,"description":61,"dateModified":94,"datePublished":95,"encodingFormat":93,"isAccessibleForFree":96,"interactionStatistic":97},"DigitalDocument",{"url":83,"@type":84,"width":85,"height":86},"https://docshare.wps.com/thumbnails/income-verification-form-self-employment-proof-of-monthly-income/280933.png","ImageObject",442,249,{"name":88,"@type":89},"Mimi","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-31","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":30},"InteractionCounter",{"@type":100},"ViewAction",{"@type":102,"mainEntity":103},"FAQPage",[104,110,114,118],{"name":105,"@type":106,"acceptedAnswer":107},"Who should use this self-employment income verification form?","Question",{"text":108,"@type":109},"Use it when you need proof of income for self-employment but do not have formal, current documentation, or when you do gig work and do not have a bookkeeper. If there are multiple self-employed household members, each should complete their own summary.","Answer",{"name":111,"@type":106,"acceptedAnswer":112},"How do you calculate the net monthly income for the summary?",{"text":113,"@type":109},"Net income is the amount left after paying business expenses and taxes. Enter gross monthly income, report monthly expenses, and use the table to compute the average monthly net amount (income or loss) and total net for the year.",{"name":115,"@type":106,"acceptedAnswer":116},"What information is required from the household head and what declaration is included?",{"text":117,"@type":109},"The form requires the head of household name, signature, date, and other member identifiers like reference/member ID and phone number. By signing, the filer swears under penalties of perjury that the information and supporting documentation are true and complete.",{"name":119,"@type":106,"acceptedAnswer":120},"How can the completed form be submitted?",{"text":121,"@type":109},"Submit it by uploading to your HIX account, faxing it to the listed number, mailing it to the Health Insurance Processing Center address, or giving it to staff at specified enrollment centers and walk-in locations. The form also provides Health Connector and MassHealth contact numbers for questions.","https://schema.org",{"og:url":78,"og:type":124,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":126,"canonical":78},"index,follow",{"doc_id":128,"site_id":56},280933,1791082587,{"code":4,"msg":5,"data":131},{"doc_id":128,"user_id":132,"nickname":88,"user_avatar":133,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":134,"file_id":135,"file_url":136,"file_type":137,"file_size":138,"view_count":30,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":73,"language":139,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":140,"faqs":141,"seo_title":142,"seo_description":61,"update_tm":143,"read_time":9},2336477974920,"https://ap-avatar.wpscdn.com/davatar_155a257f0dc6eb9ab79c44ca47cae57d","Verifcation of Self-Employment Income  \nUse this form as proof of income for self-employment.  \nYou may use this form if:  \n• you do not have formalized, current documentation of your self-employment, or  \n• you engage in gig work (rideshare, food delivery, etc.) and do not have a bookkeeper.  \nPrint  \nClear  \nSELF-EMPLOYMENT SUMMARY  \nComplete this summary based on your net monthly income. Net income is the amount of money that you have after paying your business expenses and your taxes.  \nIf you are self-employed with more than one job, use a different row for each job under “Business name/type of work,” If another member of your household is self-employed, they should fill out their own summary.  \nHead of Household Name:   Household Member Reporting Self-Employment on this form:   Reference ID/Member ID:   Phone Number:   Today’s Date:    \n\n| Business name/ type of work | Timeframe you\u003Cbr>receive income\u003Cbr>from this work | Gross monthly income | Monthly expenses* | Average monthly income or loss (net) | Total (net) for the year |\n| --- | --- | --- | --- | --- | --- |\n| Example: Smith Snowplowing | Seasonal (Dec–Apr; 5 months) | $6,000 | $500 | ($6,000-$500)=$5,500 | ($5,500 x5 months)=$27,500 |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n|  |  |  |  |  |  |\n\nTotal amount of self-employment income for member: $   Frequency (if other than yearly):   List any business expenses you have in operating your self-employment/business. These expenses would total the monthly expenses amount reported in the table above.  \nMore information about my household’s income (any variance by season/month):  \n• By signing below, I swear under the pains and penalties of perjury that everything on this form, and any supporting documentation I chose to include, is true and complete to the best of my knowledge.  \n• I know that if I lie on this form, my health coverage might end and I might have to repay Massachusetts for any tax credits or health benefts I got.  \nHead of household signature:   Date:    \n*For list of deductible business expenses, please visit [https://www.irs.gov/publications/p334](https://www.irs.gov/publications/p334), Chapter 8. Paying yourself a monthly amount is NOTa deductible expense.  \nRETURN THIS SIGNED DOCUMENT IN ONE OF FOUR WAYS  \n• Upload to your HIX account  \n• FAX it to (857) 323-8300  \n• Mail it to Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780  \n• Give this form to someone at one of these locations:  \nMassHealth Enrollment Centers Health Connector Walk-in Centers  \n529 Main Street Charlestown, MA 02129  \n88 Industry Avenue, Suite D Springfeld, MA 01104  \n367 East Street Tewksbury, MA 01876  \n100 Hancock Street, 1st Floor Quincy, MA 02171  \n133 Portland Street Boston, MA 02114  \n146 Main Street Worcester, MA 01608  \n21 Spring Street, Suite 4 Taunton, MA 02780  \nQUESTIONS  \nCall the Health Connector at (877) MA ENROLL,(877) 623-6765 or TTY: (877) 623-7773. Or call MassHealth at (800) 841-2900 or TTD/TTY: 711.","cbCaigGRAeG25Vto","https://ap.wps.com/l/cbCaigGRAeG25Vto","pdf",88234,"English","# Self-Employment Summary\n## Member and household details\n## Business income and expenses table\n## Expenses, income variance, and certification\n## Submission methods and contact information","[{\"question\":\"Who should use this self-employment income verification form?\",\"answer\":\"Use it when you need proof of income for self-employment but do not have formal, current documentation, or when you do gig work and do not have a bookkeeper. If there are multiple self-employed household members, each should complete their own summary.\"},{\"question\":\"How do you calculate the net monthly income for the summary?\",\"answer\":\"Net income is the amount left after paying business expenses and taxes. Enter gross monthly income, report monthly expenses, and use the table to compute the average monthly net amount (income or loss) and total net for the year.\"},{\"question\":\"What information is required from the household head and what declaration is included?\",\"answer\":\"The form requires the head of household name, signature, date, and other member identifiers like reference/member ID and phone number. By signing, the filer swears under penalties of perjury that the information and supporting documentation are true and complete.\"},{\"question\":\"How can the completed form be submitted?\",\"answer\":\"Submit it by uploading to your HIX account, faxing it to the listed number, mailing it to the Health Insurance Processing Center address, or giving it to staff at specified enrollment centers and walk-in locations. The form also provides Health Connector and MassHealth contact numbers for questions.\"}]","Income Verification Form (Self-Employment) - Proof of Monthly Income | PDF",1789562626]