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The form collects work schedule details, including days and hours per week, business contact information, and a description of job duties. Applicants must attach supporting documentation proving work days/hours and income, such as client lists, receipts, appointment/job logs, mileage logs, income source letters, and recent tax returns or business records. Includes parent declaration, signature date, and CHS internal review fields with revision date.",{"@graph":63,"@context":119},[64,80,102],{"@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/verification-of-self-employment-independent-contractor-may-2024/281477/",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/verification-of-self-employment-independent-contractor-may-2024/281477.png","ImageObject",442,249,{"name":88,"@type":89},"Oliver","Person",{"url":68,"name":91,"@type":92},"DocShare","Organization","application/pdf","2026-10-29","2026-09-16",true,{"@type":98,"interactionType":99,"userInteractionCount":101},"InteractionCounter",{"@type":100},"ViewAction",10,{"@type":103,"mainEntity":104},"FAQPage",[105,111,115],{"name":106,"@type":107,"acceptedAnswer":108},"What information must the parent/guardian provide on the form?","Question",{"text":109,"@type":110},"The parent/guardian must provide self-employment/independent contractor affirmation, business contact details, estimated days and hours worked per week, and a description of job duties.","Answer",{"name":112,"@type":107,"acceptedAnswer":113},"What documents are required to prove days and hours worked?",{"text":114,"@type":110},"Required documentation includes one or more of the following: client list with contact information, client receipts, appointment logs, job logs, mileage logs, or other attached schedule information.",{"name":116,"@type":107,"acceptedAnswer":117},"What documents are required to prove income?",{"text":118,"@type":110},"Required documentation includes one or more of the following: a letter from the self-employment income source, the most recently signed and completed tax return with a statement of current estimated income for tax purposes, or other business records such as ledgers, receipts, or business logs.","https://schema.org",{"og:url":78,"og:type":121,"og:title":59,"og:site_name":91,"og:description":61},"article",{"robots":123,"canonical":78},"index,follow",{"doc_id":125,"site_id":56},281477,1791475465,{"code":4,"msg":5,"data":128},{"doc_id":125,"user_id":129,"nickname":88,"user_avatar":130,"doc_module":9,"category_id":35,"category_name":36,"doc_title":59,"doc_description":61,"doc_content":131,"file_id":132,"file_url":133,"file_type":134,"file_size":135,"view_count":101,"is_deleted":4,"is_public":9,"is_downloadable":9,"audit_status":9,"page_count":9,"language":136,"language_code":57,"site_id":56,"html_lang":57,"table_of_contents":137,"faqs":138,"seo_title":139,"seo_description":61,"update_tm":140,"read_time":4,"preview_page_count":4},8796095461610,"https://ap-avatar.wpscdn.com/davatar_276721f389ce27ea32af1340a28f341c","CHILDREN’S HOME SOCIETY OF CALIFORNIA  \nVERIFICATION OF SELF-EMPLOYMENT / INDEPENDENT CONTRACTOR  \nIn order to comply with state regulations, verification of days/hours worked and income as a self-employed person are required to determine eligibility and need for child care. Complete this form and sign the declaration below. Be sure to attach the additional documentation specified below.  \nParent/Guardian Name (Print):    \nParent/Guardian Statement: I affirm, under penalty of perjury, that I am self-employed or an Independent Contractor. My schedule, including a description of my employment and an estimate of the days and hours I work per week, is listed below. I have attached supporting documentation in order to demonstrate the days and hours that I work. I declare this information is true and correct. I understand that a willful statement of false information for the purpose of receiving subsidized child care services is considered fraud and is an offense punishable by law. If I have provided client information, I authorize Children’s Home Society of California to contact those clients to verify information as necessary.  \nParent/Guardian Signature:   Date:    \nName of Business:   Type of Business:   Business Telephone:   Business Address:   Estimated Days that may be worked (check as applicable): Sun Mon Tue Wed Thu Fri Sat Estimated number of hours per week: Minimum:   Maximum:   Hours worked between   and   (Example: between 8:00am and 6:00pm)  \nDescribe your employment, including your job duties performed.  \nYou must attach the following additional documentation to this form. Ifthe additional documentation is not attached, this form will be considered incomplete and outstanding and be cause for denial or termination ofservices.  \n1. One or more of the following to demonstrate days and hours worked:  \nList of Clients with Contact Information Client Receipts Appointment Logs Job Logs  \nMileage Logs Other schedule information attached:    \n~AND~  \n2. One or more of the following to demonstrate income:  \nA letter from the source of self-employment income  \nMost recently signed and completed tax return with a statement of current estimated income for tax purposes Other business records (such as ledgers, receipts or business logs)  \nCHS Office Use Only: Check One: 􀂅 Primary 􀂅 Secondary 􀂅 Other:   Staff Initials:    \nNotes:    \nRev. 5/2024","cbCaim4zNlZVxdvY","https://ap.wps.com/l/cbCaim4zNlZVxdvY","pdf",251922,"English","# Parent/Guardian Declaration\n## Work Schedule and Employment Details\n## Required Supporting Documentation\n## CHS Office Use Only","[{\"question\":\"What information must the parent/guardian provide on the form?\",\"answer\":\"The parent/guardian must provide self-employment/independent contractor affirmation, business contact details, estimated days and hours worked per week, and a description of job duties.\"},{\"question\":\"What documents are required to prove days and hours worked?\",\"answer\":\"Required documentation includes one or more of the following: client list with contact information, client receipts, appointment logs, job logs, mileage logs, or other attached schedule information.\"},{\"question\":\"What documents are required to prove income?\",\"answer\":\"Required documentation includes one or more of the following: a letter from the self-employment income source, the most recently signed and completed tax return with a statement of current estimated income for tax purposes, or other business records such as ledgers, receipts, or business logs.\"}]","Verification of Self-Employment / Independent Contractor - May 2024 | PDF",1789566381]