SELF-EMPLOYMENT SUMMARY

Verifcation 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

MonthDayYear
Date

Timeframe you receive income from this work

	Example: Smith Snowplowing	Seasonal (Dec–Apr; 5 months)	$6,000	$500	($6,000-$500)= $5,500	($5,500 x5 months)= $27,500

Average monthly income or loss (net)
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)
- 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 benefts I got.
Date

MonthDayYear
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 Charlestown, MA 02129 88 Industry Avenue, Suite D Springfeld, MA 01104 21 Spring Street, Suite 4 Taunton, MA 02780

367 East Street Tewksbury, MA 01876

100 Hancock Street, 1st Floor

133 Portland Street Boston, MA 02114 146 Main Street Worcester, MA 01608
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.
Should be Empty:

SELF-EMPLOYMENT SUMMARY

RETURN THIS SIGNED DOCUMENT IN ONE OF FOUR WAYS

QUESTIONS