Form H1049, Client's Statement of Self-Employment Income

Instructions

Updated: 4/2024

Purpose

To provide a method for households to report self-employment income and expenses, if accurate tax or business records are not available.

Procedure

When to Prepare

HHSC staff give Form H1049 to each household member with self-employment income. The household completes all items on the form. It must be signed and dated by the head of household (HOH), responsible household member or authorized representative.

HHSC staff may help the household complete the form and sign as helping to fill out the form. HHSC staff must return receipts, invoices or other verification documentation provided by the household.

Number of Copies

An original and one copy.

HHSC staff may give the household additional blank copies of the form to help document income and expenses for future certifications.

Transmittal

Give or mail the original to the household. Scan and file an electronic copy in the case record.

Detailed Instructions

Each household member with self-employment income completes a Form H1049 for each type of self-employment income.

1. Name (person getting money from self-employment): — Enter name of the household member with self-employment income.

2. What type of work do you do to earn this money? — Enter the type of self-employment such as commission, commission and sales, construction or repair work, contract or seasonal work, farming, odd jobs, rental income, sales or other. 

3. How many hours do you work each week? — Enter the total number of hours worked each week for the type of self-employment income.

4. Fill out the table below to tell us how much money you get from self-employment. — Complete the self-employment income table.

Date — Enter the date self-employment income is received.

Who paid this money — Enter the name of the person or business making the payment.

Amount paid — Enter the amount the person or business paid.

5. Fill out the table below to tell us how much it costs you to work (self-employment expenses). — Complete the self-employment expenses table.

Date — Enter the date self-employment expense is incurred.

Type of expense — Enter the type of self-employment expense such as advertising, car and truck expenses, commissions and fees, contract labor, depreciation, employee benefit programs, insurance, interest,  legal and professional services, net loss from a previous period, office expense, pension and profit-sharing plans, rent or lease, repairs and maintenance, supplies, tax and licenses, travel, meals or entertainment, travel to and from place of business, utilities, wages or other expenses. 

Amount paid — Enter the amount of the expense.

Signature of person getting self-employment income — The person receiving the self-employment income signs the form.

Date — Enter the date the person receiving the self-employment income signs the form.

Signature of anyone helping you fill out this form — If applicable, the person helping fill out the form signs the form.

Date — Enter the date the person helping fill out the form signs the form.

For Agency Use Only — HHSC staff complete the following blanks on the form.

Case No. — Enter the household’s case number.

Case Name — Enter the HOH’s name.