UI / DE 8595

SAMPLE, this page for reference only

EDD Employment Development Department State of California Logo

FOR FO USE ONLY
FEMA #
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Disaster Name
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SELF-EMPLOYED INDIVIDUAL STATEMENT OF WAGES OR EARNINGS

Name
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SSN #
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You may choose to establish your claim based on the wage information on this form. If you choose to establish your claim based on this form, you must provide proof of those wages by
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Proof includes, but is not limited to: check stubs, W-2, 1099, income tax forms, business records.
  1. ENTER SELF-EMPLOYMENT EARNINGS FOR THE PRIOR COMPLETED TAX YEAR.
    PRIOR COMPLETED TAX YEAR
    Begins
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    Ends
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    Gross Earnings
    $Blank line 
    Subsidies
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    subtotal
    $Blank line 
    Business Expenses
    -Blank line 
    NET EARNINGS
    $Blank line 
    (From 1040 Schedule C, line 32)
  2. ENTER YOUR HIGHEST QUARTER OF PROFIT FOR THE PRIOR COMPLETED TAX YEAR.
    Quarter 1 Begins
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    Ends
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    Quarter 3 Begins
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    Ends
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    Quarter 2 Begins
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    Ends
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    Quarter 3 Begins
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    Ends
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High Quarter Ending Date
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Gross Income
$Blank line 
Itemized Expenses (use extra sheet if necessary)
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$Blank line 
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$Blank line 
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$Blank line 
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$Blank line 
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$Blank line 
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$Blank line 
Total Expenses
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Profit
$Blank line 
I certify the information supplied on this form for the purpose of obtaining Disaster Unemployment Assistance (DUA) is true and correct and that I am unemployed as a direct result of the disaster. I have been advised that these are Federal funds and that penalties are provided by law for willful misrepresentation or falsification of material facts in order to obtain benefits.
APPLICANT'S SIGNATURE:
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DATE:
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DE 8595 (1-97) (INTRANET) State of California / Employment Development Department