Verification of
Self-Employment Income
Use this form as proof of income for self-employment.
You may use this form if:
•
you do not have formalized, current documentation of your self-employment, or
•
you engage in gig work (rideshare, food delivery, etc.) and do not have a bookkeeper.
SELF-EMPLOYMENT SUMMARY
Complete this summary based on your net monthly income. Net income is the amount of money that you have after paying your
business expenses and your taxes.
If you are self-employed with more than one job, use a different row for each job under “Business name/type of work,” If another
member of your household is self-employed, they should fill out their own summary.
Head of Household Name: _______________________________________________________________________________
Household Member Reporting Self-Employment on this form: ______________________________________________________
Reference ID/Member ID: _______________________________________________________________________________
Phone Number: ____________________________________ Today’s Date: ______________________________________
Business name/
type of work
Timeframe you
receive income
from this work
Gross monthly
income
Monthly expenses* Average monthly
income or loss (net)
Total (net) for
the year
Example: Smith
Snowplowing
Seasonal (Dec–Apr;
5 months)
$6,000 $500 ($6,000-$500)=
$5,500
($5,500 x5 months)=
$27,500
Total amount of self-employment income for member: $ ________ Frequency (if other than yearly): _________________________
List any business expenses you have in operating your self-employment/business. These expenses would total the monthly expenses
amount reported in the table above.
More information about my household’s income (any variance by season/month):
INVF-0922
Print
Clear
• By signing below, I swear under the pains and penalties of perjury that everything on this form, and any supporting documentation I
chose to include, is true and complete to the best of my knowledge.
• I know that if I lie on this form, my health coverage might end and I might have to repay Massachusetts for any tax credits or health
benefits I got.
Head of household signature: ___________________________________________ Date: ___________________________
*For list of deductible business expenses, please visit https://www.irs.gov/publications/p334, Chapter 8. Paying yourself a monthly amount
is NOT a deductible expense.
RETURN THIS SIGNED DOCUMENT IN ONE OF FOUR WAYS
•
Upload to your HIX account
•
FAX it to (857) 323-8300
•
Mail it to Health Insurance Processing Center, PO Box 4405, Taunton, MA 02780
•
Give this form to someone at one of these locations:
MassHealth Enrollment Centers Health Connector Walk-in Centers
529 Main Street 367 East Street 133 Portland Street
Charlestown, MA 02129 Tewksbury, MA 01876 Boston, MA 02114
88 Industry Avenue, Suite D 100 Hancock Street, 1
st
Floor 146 Main Street
Springfield, MA 01104 Quincy, MA 02171 Worcester, MA 01608
21 Spring Street, Suite 4
Taunton, MA 02780
QUESTIONS
Call the Health Connector at (877) MA ENROLL, (877) 623-6765 or TTY: (877) 623-7773. Or call MassHealth at (800) 841-2900
or TTD/TTY: 711.
