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The form collects case or member identification, the business name, and each owner’s ownership percentage. It requires selecting the business operating period, reporting gross income and business expenses for the specified timeframe, and indicating whether the owner pays wages or salary. 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Typed signatures are not valid, and you must include the member or authorized representative signature and today’s date.","https://schema.org",{"og:url":78,"og:type":120,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":122,"canonical":78},"index,follow",{"doc_id":124,"site_id":56},281474,1790271496,{"code":4,"msg":5,"data":127},{"doc_id":124,"user_id":128,"nickname":88,"user_avatar":129,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":130,"file_id":131,"file_url":132,"file_type":133,"file_size":134,"view_count":8,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":135,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":136,"faqs":137,"seo_title":138,"seo_description":61,"update_tm":139,"read_time":4,"preview_page_count":4},5909877438554,"https://ap-avatar.wpscdn.com/avatar/5600025385ad2bf12a7?_k=1778553567797529272","SELF-EMPLOYMENT/CASH INCOME STATEMENT  \nSECIS FORM  \nIf you or any member of your household has any self-employment income or cash income, you may fill out this form to meet the verification request. You may also submit a copy of your own accounting statement or profit and loss statement. You must answer all questions on this form and sign and date it at the bottom.  \nFill out a separate form for each business you have.  \nIf you have questions, please call the SoonerCare Helpline at 800-987-7767.  \n1. Case number or Member ID number    \n2. Business company name    \n3. List the owners of the business with the percentage of business owned  \n\n| Name of business owner | Percentage of business owned |\n| --- | --- |\n|  |  |\n|  |  |\n|  |  |\n\n4. Check ONE box below that applies to the business owner regarding business income.  \nThe business has been in operation for one year or more.  \n• What was the total gross business income for the past 12 months?    \n• What were the total business expenses for the past 12 months?    \nThe business has been in operation for less than one year.  \n• How long has the business been in operation?    \n• What was the total gross business income for this time period?    \n• What were the total business expenses for this time period?    \n5. Check ONE box below that applies to the business owner regarding wages.  \n5a. Yes, as the business owner listed above, I pay myself a wage or salary from the business. (If yes, you are required to provide the last 30 days of paystubs with this form. )  \n5b. No, as the business owner listed above, I do not pay myself a wage or salary from the business.  \nSelf-employed or cash Income includes money from sales, cash receipts, crops, commissions, leases, fees or whatever you do to sell for money. If you have any other kind of income from your business, be sure to include it.  \nBusiness expenses are your costs of doing business. Examples of expenses are supplies, repairs, rent, utilities, seed, feed, business insurance, licenses, fees, payments on principles of loans for income-producing property, and capital asset purchases. If you have anyother type of business expenses, be sure to include them.  \nThe information I give on this worksheet is true and correct to the best of my knowledge. I realize if I give information that is not true or if I withhold information, I can be lawfully punished for fraud and/or perjury. I may also have to repay the State of Oklahoma for any payments or claims incurred which were paid based on representations that I made herein. (OAD 317:35-13-6 and OAC 317:35-13-7)  \nThe signature must be handwritten or drawn with your cursor. Typed in signatures are not valid.  \nMember or Authorized Representative Signature Today’s Date  \nSECIS – Revised 05/2025","cbCaia9Wul3CnLBk","https://ap.wps.com/l/cbCaia9Wul3CnLBk","pdf",173892,"English","# Self-Employment/Cash Income Statement (SECIS) \n## Purpose and submission requirements\n## Business and owner details\n## Business income and expenses by operating period\n## Wages to the business owner\n## Definitions for income and business expenses\n## Attestation, signature, and date","[{\"question\":\"What information must be provided on the SECIS form?\",\"answer\":\"Provide a case number or Member ID, the business company name, and each owner’s ownership percentage. You must also answer the income and expense questions based on the business’s operating timeframe and indicate whether you pay yourself wages or salary.\"},{\"question\":\"Do I need to submit a separate SECIS form for each business?\",\"answer\":\"Yes. Fill out a separate form for each business you have.\"},{\"question\":\"What are the signature requirements for the SECIS form?\",\"answer\":\"The signature must be handwritten or drawn with your cursor. Typed signatures are not valid, and you must include the member or authorized representative signature and today’s date.\"}]","Self-Employment/Cash Income Statement - SECIS Form - Revised 05/2025 | PDF",1789566354]