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

Instructions for Opening a Form

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Effective Date: 12/2015


Updated: 7/2004


To provide

  • a means by which a client may report self-employment income and expenses if accurate tax or business records are not available; and
  • a means for computing a client's net monthly income from self-employment.
  • a means for calculating income for qualifying households with a farm loss.


When to Prepare

The worker gives page 1-2 of Form H1049 to each client with self-employment income. The client completes all items on the form. It must be signed and dated by the applicant, spouse, or authorized representative.

The worker may assist in completing the form. If so, the worker either initials each entry made (the client must initial the entry also) or signs as having helped prepare the form.

Workers must return receipts, invoices, or other verifying papers provided by the client as soon as possible.

Number of Copies


The worker may give a supply of Form H1049 for clients to use in recording income and expenses for future certifications.


File Form H1049 in the case folder with the corresponding Form H1010-B.

Form Retention

Keep Form H1049 for three years. If other documents are submitted in place of, or in addition, to Form H1049, also keep copies of these documents for three years.

Detailed Instructions

Instructions for the client-completed portion of the form are on Page 2 of the form.

The worker must document verification or computations on Page 3 of Form H1049 or on the Food Stamp or TANF Worksheet.

Section I — Calculate annual or seasonal self-employment income. Document the projection period in Section IV.

Section II — Calculate all other self-employment frequencies except annual or seasonal.

Section III — Calculate farm loss.

Section IV — Document verification and method used to calculate self-employment income.