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APPENDIX G Effective: April 1, 2026

Self-Employment Self Certification Form Use this form to list the gross income, business expenses, and net income after business expenses from your self-employed business. Do not include any depreciation as a business expense. You must provide a copy of your most recent federal income tax return with all accompanying schedules for the most recent year ending December 31st. If self-employment recently began, the tax return has not been filed, or it is after April 15th, you must also complete this form attesting to current monthly earnings and losses supported by the corresponding bank account statements. 1. Name of Person Having Self-Employment Income (Applicant, or any other Household member over 18 years of age)

2. Give the time period covered by this income statement. ........................................................ 3. Describe what you did to earn this money:

4. List your business income and expenses (IMPORTANT: Attach copy of bank statements, or other verifying papers).

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The above information is true, correct, and complete to the best of my knowledge. I understand that giving false information to receive assistance from the Louisiana Low-Income Home Energy Assistance Program could result in fraud penalties.

Signature Date Signature Date

DATE EXPENSES

AMOUNT $ TOTAL SELF-EMPLOYMENT EXPENSES $ DATE INCOME AMOUNT $ TOTAL SELF-EMPLOYMENT INCOME $ ENTER HERE AND SUBTRACT

– NET SELF-EMPLOYMENT INCOME $