Free DHS F-16034 SELF-EMPLOYMENT INCOME WORKSHEET - Corporation - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-16034 (05/09)

STATE OF WISCONSIN 7 CFR 273.11 (a)(2)

SELF-EMPLOYMENT INCOME WORKSHEET - Corporation
Tax Year Filing Case Name Worker Name Case Number Worker ID Date Completed

If the participant is the sole owner of the corporation, or if the percent of the corporation the benefit group owns is known, skip STEP I, begin with STEP II and enter 1.00 or the percent owned if less than 100%, on line 6, STEP II. If the participant is not the sole owner and the percent of ownership is not 1 known, begin with STEP I.

STEP I: CALCULATE THE PERCENT OF OWNERSHIP If ownership is divided into shares, complete (1) through (3). If not, complete (4) through (6). Use owner's report to determine the percent of ownership. (1) Enter number of shares owned by the participant (2) Enter number of shares outstanding in the corporation (3) Divide (1) by (2) - equals owner's share of corporation Alternate method (4) Enter total investment in the corporation by participant (5) Enter total investment by all owners (6) Divide (4) by (5) - equals owner's percentage of the corporation2 (4) $ (1) (2) ÷ (3) =

(5) ÷ $ (6) = $

STEP II - CALCULATE OWNER'S SHARE OF CORPORATE IM-INCOME (1) (2) (3) (4) Enter taxable income Add depreciation back in (Enter zero if negative.) Add depletion back in (Enter zero if negative.) Subtract total taxes

From IRS Form 1120 from line 30 from line 20 from line 21 from line 31 (1) $

(2) + $ (3) + $ (4) - $

(5) (6) (7)

Equals IM-Income for the corporation Enter owner's percentage of the corporation Equals owner's share of corporate income

( add (1) through (4) ) ( from STEP I (3) or (6) ) ( multiply (5) by (6) ) enter dividends received from line 4

(5) = $ (6) x (7) = $ (8) - $ (9) = $ (10) = $

(8) Subtract dividends received by client from this corporation during the period covered (9) Equals owner's share corporate IM-Income ( add (7) and (8) )

(10) Divide line (9) by the number of months in operation to get monthly average
1

2

If more than one owner is in the benefit group, perform STEP I for each owner in the group. Then total the individual owners' portions before entering on line (6), STEP II. If owner's share [line (3) or (6), STEPI] is .50 (50% or less), stop and consider the corporate income to be unavailable; thus, on line (9), STEP II, enter zero. Exception: If the total share owned by the Food Unit, BC+ Test Group, or EBD Fiscal Group is greater than 50%, the income is available; continue completing the worksheet for each member. For example, if a husband, owning 40%, and wife, owning 40%, apply for assistance and are part of the same AG, the corporate income is available and you will continue completing the worksheet for each owner.

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