MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY SELF-EMPLOYMENT AFFIDAVIT PAGE 1 OF 3
REV 032021
2. (If different from above) When the events described in this affidavit took place, I was known as
_______________________________________________________________________________________
1. My full legal name is
_______________________________________________________________________________________
4. My Social Security number is ____________________________________________________________
5. Driver’s license or state issued ID card number is __________________________________________
6. My current address is __________________________________________________________________
City ______________________________________ State ___________ Zip Code _________________
8. My daytime telephone number is _________________________________________________________
9. My evening telephone number is _________________________________________________________
SELF-EMPLOYMENT AFFIDAVIT
PERSONAL INFORMATION
FIRST MIDDLE LAST JR., SR., III
FIRST MIDDLE LAST JR., SR., III
3. My date of birth is __________ / __________ / _______________
DAY MONTH YEAR
Issuing State _______________ Expiration Date: __________ / __________ / _______________
DAY MONTH YEAR
7. I have lived at this address since __________ / _______________
MONTH YEAR
MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY SELF-EMPLOYMENT AFFIDAVIT PAGE 2 OF 3
REV 032021
Nature of Business ___________________________________________________________________
Occupation/Worked Performed ________________________________________________________
Average Hours Worked Weekly ________________________________________________________
How do you get paid? MARK ALL THAT APPLY CASH CHECK Other
Business Name _____________________________________________________________________
Business Address ___________________________________________________________________
City ___________________________________ State ___________ Zip Code _________________
Self-Employment Information
BUSINESS DETAILS
Note: If you do not work under a business name, provide your name and contact information.
Business Start Date __________ / __________ / _______________
DAY MONTH YEAR
Last Day Worked __________ / __________ / _______________
DAY MONTH YEAR
MISSISSIPPI DEPARTMENT OF EMPLOYMENT SECURITY SELF-EMPLOYMENT AFFIDAVIT PAGE 3 OF 3
REV 032021
Signature
I declare under penalty of perjury that the information I have provided
in this affidavit is true and correct to the best of my knowledge.
Knowingly submitting false information on this form could
subject you to criminal prosecution for perjury.
Signature ______________________________________________________
Date Signed __________ / __________ / _______________
DAY MONTH YEAR
DAY MONTH YEAR
You must have one witness (non-relative) that can verify your self-employment.
Witness should complete the below information and sign.
Date Signed __________ / __________ / _______________
Witness: _________________________________________________________________
Signature: _______________________________________________________________
Telephone Number: _____________________________________________________
PRINT NAME
