ࡱ> IKHa bjbj 8M\M\a ,,,8d,k8*www7777777$;K>^8.ww..8%8###.j7#.7##v56wq 67;80k806>& >,6>6wr#\Iwww88!wwwk8....>wwwwwwwww > :  Self-Employment Certification This form is to provide income documentation for families who are self-employed. To receive subsidized child care, you are required to provide all documentation for total countable income for the self-employed family members who are counted in the family size. Name of Business: ______________________________________________________ Business License (if applicable):_______________________________________________ Address of Business: _______________________________________________________ City: __________________ State: _______ Zip Code: __________ Phone: ___________ Federal Tax I.D.: _____________________or State Tax I.D.: _____________________ Days of Employment: Sun ____ am _____pm Mon ____ am ______pm The specific times you work. Tues ____ am _____ pm Wed ____ am _____ pm Thur ____ am _____ pm Fri _____ am ______pm Sat _____ am _____ pm Hours Worked per week ____ Salary Information: Gross Monthly Salary or: $ ____________________ Hourly Rate: $ ____________________ Weekly Rate: $ ____________________ Deductions or Expenses: $ ____________________ I understand that the above information pertains to the employees eligibility for child care benefits and is subject to verification by representatives of the Ƶ Child Development Center, and/or the California Department of Education. Under penalty of perjury I affirm that, to the best of my knowledge, the above information is true and correct. _________________________________________ _________________________ Print Authorized Employer Representative Date _________________________________________ _________________________ Authorized Employer Representative Signature Date     Ƶ Child Development Center 900 Rancho San Diego Parkway, El Cajon, CA 92019 619.660.4660 Fax 619.660.4603 "+t' ) 3 B  * U Y [ m p ξxmht"h)CJaJh>[h5 h)6h>[h)6 h6hh)5h>)58<h)h)OJPJQJaJhPJaJh<PJaJh^qh)PJaJh^qh)CJ$PJaJh^qhJCJPJaJh-~fjh+U*!"( ) s t   e f ! , - i gd)$a$gd)$a$gd+ % , - 5 9 Q T v  # 4 U i s M`abdeghjkmƿᰫῘyhghe@"CJOJQJ^JhYCJOJQJ^JhLjhLUh7h^qCJaJ h85hk-h^q5 h^qh8 h^qh^qh^qh^qPJaJh8PJaJh^qPJaJh^qh8ht"h)CJaJh>[h)5h)/i s ^ acdfgijlmgde@"$ L*$1$]L^a$gde@"gd^q ^`gd^q^gd^q h^qh^qhLhe@"hYCJOJQJ^Jhghe@"CJOJQJ^J gd^q6&P1:pe@"/ =!"#$% } Dd | T r<  C A2 +ԯ+b DV`! +ԯ+b` x pT{oAA@Q#&1*DAQ( 8QTLeP@%*4R"Xj$#6UP@ʇT(d b܁ #peѮô13{ι.a-vc:0民Ё'@C;sezpj,+-a$f-%Ǿ}`7YXgh^|7w+Ujۋi7;8~N?Ot!hgbϩ :8{/mn.jUj{SVmךlrRl]lٟS6XFrT'CM'tJ>Vc;H;Դ>۳⭱'_<3 {.μ^JT0nߖfwj۷yTPC 8'8nefߥyF1̙Üm18'%g>^PʟΧ56c`:,`6[ w zb=/G3('۴e?nYW/_ e~ ם<#y3 εٯˑSgsY:Ẏ@Q^0k?rI:ve}s[9x+ f֒~4:l'L'`Yb(+`sD.: =q {c>] a=D 5\qYg+vPW*cef6yaY$y":%l)qȱf\gE+z= 22)f8VlUu{41dHh$wUȋ4!kc4q>72 G[\$aܫ7u>[̋$,rx7:,=TE=;DNj%a)k1)Uԣ$ >l&#׉\k{ HX@-$&l{Ÿd&Ϥ)%xpE) WIX8o)DWn8CrюER.rn7B}2u n'a )_AwQHRfl˕le56\|Dz)2&EBy]JMr-WgQW&?esd3@,xus$y\:GWU!_ȵ|5K~nM_Zc0u`= 2J 뱾*8ӷL~.KV5='v x{UbOwBKY޳W^ž^ }rh.lHEr*ɓHX#er"U2 ܓm!6eoȓ$,o er8"sKI\G)2Q wdDF ֌02)HI?v8Mg̗elS*qSkYɁ )Bl\-r_+sN9.Aɲ):sdS!:a$#!%$wJL^t/I!6峤"d.91Q5#,+H|T SITu!bZOe54A$FRssITHَ{8ӧŸmZ#!ϳZjR??<T"6b٦9umDDޏɿ-1_g:ݎь 6<=;FK|=h7ZgKqҨ7_J_"Ć5#\cjzlI/17)AlxMRwuЯX3oVhZµu 6<]F^Hv蕤A#X3|h ;KI~>fח_CDO!=4vlз#wj#XxzWG1R"knRŎQ/%ku&B4INDJvБI/8q="z:b/&ӊz)r7v `}$BR?ww=^yL6b4oN{[OpWD:3~$}w`cz0g鱐O!c$E!F""6pѠF#֌!UgMR72M49#5WcyRQ׌cHmڅU3#6&0 u;7\o%a"!s2 0@P`p2( 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p 0@P`p8XV~ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@ 0@_HmH nH sH tH D`D NormalCJOJQJ_HmH sH tH DD  Heading 1$$@&a$ 56CJ$DD  Heading 2$$@&a$ 56CJ LL ? 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