Form 3051, Statement of Self-Employment Income

Instructions for Opening a Form

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Effective Date: 11/2019



Updated: 11/2019



Form 3051 is completed if an applicant (or any member of their household) applying for health care assistance through the Primary Health Care Services Program, the Title V Fee-for-Service Program and/or the Epilepsy Program has any kind of self-employment income. Self-employment income is any money the applicant earns working for himself or herself (not money earned working for someone else).


When to Prepare

The applicant completes Form 3051 and attaches it to Form 3029, Application for Program Benefits. The applicant may attach a copy of the latest income tax forms in place of Form 3051. If the applicant’s accounting system is not the same as this form, the applicant may substitute a copy of the accounting statement.

The applicant will need to bring the following to the eligibility interview in the clinic for the eligibility worker to review. These records will be returned to the applicant:

  • Bills
  • Receipts
  • Checks or Stubs
  • Any other Business Records


Number of Copies

The applicant completes an original and gives it to the eligibility worker at the eligibility interview.


Form Retention

The eligibility worker keeps the original form for three state fiscal years after services are rendered.


Detailed Instructions

The applicant must answer all questions and sign and date the form. Additional sheets of paper may be added to Form 3051, but each sheet must be signed and dated as this form is a sworn statement.

Case Name – Enter the case or applicant’s name.

Case No. – Enter the case number.

Name of Person with Self-Employment Income – Enter the applicant’s name or member of the household with self-employment income.

Number of Months Covered by this Income Statement – Enter the number of months.

Describe what Person Did to Earn this Money – The applicant or person completing the form describes the type of work done.

List Business Expenses and Income – The applicant or person completing the form lists any business expenses and income in the tables. Expenses are the costs of doing business and examples include supplies, repairs, rent, utilities, seed, feed, business insurance, licenses, fees, payments on principal of loans for income-producing property, capital asset purchases (such as real property, equipment, machinery, and other durable goods and capital asset improvements), the Social Security contribution for people who worked for the applicant or household member, and labor (not the salary the applicant paid himself or herself). If the applicant claims labor costs, list each person and the amount paid to that person. If there are any other kinds of business expenses, list each and the date they were paid.

The applicant or person enters the date the expense was paid, the type of expense and amount for each expense. The applicant may not claim:

  • Rent, mortgage, taxes or utilities on the business if it operates out of the applicant’s home (unless these costs are separate from the costs of the home);
  • Cost of goods the applicant buys for the business but uses himself or herself;
  • Net business loss from a prior period; and
  • Depreciation.

If the applicant is unsure about what is an expense, he or she may ask the eligibility worker and provide proof of that expense.

The applicant totals the amounts of all expenses in the Total Expenses column.

The applicant then provides the date the income was received, the kind of income from the business and the amount. Income includes money from sales, cash receipts, crops, commissions, leases, fees or whatever the applicant or household member does or sells for money.

The applicant totals the income and enters in the Total Income column. The applicant subtracts the amount of Total Expenses to get the Net Self-Employment Income amount.

Signatures – The form must be signed by the person helping the applicant to complete the form, if applicable, and by the applicant, spouse or authorized representative.

Date – The date of the signatures must be entered on the form.