DWS-ESD 452

Express of Utah

Department of Workforce Providers

SELF-EMPLOYMENT DATA SHEET

Rev. 2/2007

PLEASE USE A DARK-COLORED BALL LEVEL PEN TO COMPLETE FORM

Self Employed Person

Business Name:

E20512585050103: 8505388

Case #:

Soc. Sec #:

Month of:

twenty

K OSMOND

Number of hours

worked this month:

1 . Can be your business incorporated?

Yes

No

If yes, do you have stock?

Yes

No

Do you really file taxation as a great 'S' Corp.?

Yes

Zero

Yes

No

Is your company a partnership?

Yes

Zero

Are you a limited partner?

Certainly

No

2 . Are you sole owner of your business (If yes, go to #3)

What is the percentage of ownership?

%

3. Did your business involve rental/lease profits?

Yes

4. How long are you currently doing business?

Not any

Years

Are you involved in the everyday decisions of your business?

Certainly

No

Will you consider yourself actively involved in your business?

Certainly

No

Yes

No

a few. Is your company in your home?

If yes, what percentage of your home is usually regularly & exclusively employed for business Is usually your business per day care?

%

Yes

If you do, what percentage of your home is employed for day care?

No

%

6. Do you use a motor vehicle in your organization?

Yes

Certainly

If yes, would it be used only for business?

Zero

No

%

If simply no, what percentage is used for people who do buiness?

7. Do you have a separate business phone?

Certainly

No

eight. Do you have separate business looking at or savings account? (provide copy)

Yes

Not any

The above is actually a correct statement of my personal self-employment information. Customer Personal:

Date:

Equal Opportunity Workplace Program

Auxiliary aids and services can be found upon demand to individuals with disabilities by simply calling (801) 526-9240. Individuals with speech and hearing impairments may call Relay Ut by dialing 711. The spanish language Relay Utah: 1-888-346-3162.

Point out of Utah

Department of Workforce Providers

SELF-EMPLOYMENT LEDGER

E20512585050203: 8505388

K OSMOND...

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