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Tips/ Self-Employment Statement

Name:______________________________________ Date:___________________

Place of Employment:__________________________ Phone #:________________

Job Description:__________________________________________________________________
(Example: wait staff; cab driver, nail technician, barber/hair stylist etc.)

Week 1 Dates: Week 2 Dates: Week 3 Dates: Week 4 Dates: Week 5 Dates: Week 6 Dates:

Sun: $______ Sun: $______ Sun: $______ Sun: $______ Sun: $______ Sun: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Mon: $______ Mon: $______ Mon: $______ Mon: $______ Mon: $______ Mon: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Tues: $______ Tues: $______ Tues: $______ Tues: $______ Tues: $______ Tues: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Wed: $______ Wed: $______ Wed: $______ Wed: $______ Wed: $______ Wed: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Thurs: $______ Thurs: $______ Thurs: $______ Thurs: $______ Thurs: $______ Thurs: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Fri: $______ Fri: $______ Fri: $______ Fri: $______ Fri: $______ Fri: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Sat: $______ Sat: $______ Sat: $______ Sat: $______ Sat: $______ Sat: $______
Hours:______ Hours:______ Hours:______ Hours:______ Hours:______ Hours:______

Total Total Total Total Total Total


Tips/Income Tips/Income Tips/Income Tips/Income Tips/Income Tips/Income
Earned Earned Earned Earned Earned Earned
$________ $________ $________ $________ $________ $________
Total Hours Total Hours Total Hours Total Hours Total Hours Total Hours
Worked Worked Worked Worked Worked Worked
_______ _______ _______ _______ _______ _______

I attest that the information provided above is an accurate reflection of my income from tips or self-
employment. This statement is made under the penalty of perjury (a first degree misdemeanor punishable by
a definite term of imprisonment, not exceeding one year and/or a fine not exceeding $1,000 pursuant to
s.837.012, or 775.082, or 775.083, F.S.)

Signature:____________________________________________________ Date:____________

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