INCOME INFORMATION Specify your income information. Describe how you get paid.
(Example: Per Job. $50 per house; 10% per sale) BUSINESS SUPPORT DOCUMENTATION Attach documentation to verify your business activity and income. (Attach all that apply): Business License Mileage Log Receipts for Expenses Advertising Materials Appointment/Job Log Quarterly Tax Statement Rental/Lease Agreement Client List/Contact Information Receipts for Service/Product Tax Return Invoice for Service/Product Business Profit/Loss Statement
If applicable, what is your business website address and/or social media platform(s)
I declare under penalty of perjury, that the information regarding my self-employment is true and correct. I understand to increase days or hours between certification periods, documentation of need to support the increase & Request to Change Services form is required. I understand that increases will not be backdated. I give San Bernardino County Superintendent of Schools permission to obtain the information necessary to verify and support my days/hours worked by contacting clients, landlord or others deemed necessary.
Parent/Gu ardian Nam e
Date
FOR OFFICE PURPOSES ONLY
Date Verified
Verified With
Staff Initials
Notes
2/22
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