Michigan DHS Self-employment Form


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How to Fill Out the Michigan Self-Employment Form

If you're a self-employed individual in Michigan, you might need to fill out the form, formally known as the MDHHS-5762 Self-Employment Income Statement. This form is for reporting your income to the Michigan Department of Health and Human Services (MDHHS) for programs like the Michigan Drug Assistance Program (MIDAP).

In this expert-level guide, we'll walk you through the process of completing this form, ensuring that you understand each section and can provide the required information accurately.

Section I: Demographics

The first section of the form is straightforward but essential. Here, you provide your personal and business details.

  • Client’s First Name and Last Name: Enter your full legal name as it appears on official documents.
  • MIDAP Number: This is your unique identification number for the Michigan Drug Assistance Program. If you don’t have one, you may need to contact your case manager or the program’s helpline.
  • Business Name and Type of Business: Specify the name of your business and the type of services or products you offer. For instance, you might write "Jane's Freelance Writing" and "Content Creation Services."
  • Owner’s Name: If you are the sole proprietor, this will be your name. If your business has multiple owners, list the primary owner’s name.
  • Business Address: Provide the complete address of your business, including city, state, and zip code.

Section II: Income

dhs self-employment form screenshot of sections 1 and 2

This section is the core of the form where you detail your income over the last 30 days.

  • Source of Income: Describe each source of income. This could include payments from clients, sales of products, or other business-related income.
  • Date Income Received: Enter the dates on which you received the income. Be as precise as possible, as this ensures accuracy in your reporting.
  • Amount: List the amount received for each source of income.

After listing all income sources:

Total Income: Calculate and enter the total amount of income received in the last 30 days. This is a simple sum of all the amounts listed above.

Section III: Certification

dhs self employment form PDF Section 3 screenshot

This final section is about certifying the accuracy of the information you've provided.

  • Applicant’s Printed Name: Print your full name clearly.
  • Applicant’s Signature: Sign the form to confirm that the information you have provided is accurate and true.
  • Date: Enter the date you are signing the form.

If you have a case manager, they will need to fill in their information as well.

Tips for Completing Michigan Self-employment Statement

  • Accuracy is Key: Ensure that all the information you provide is accurate. Double-check dates and amounts before submitting.
  • Documentation: Attach any required proof of your business's legitimacy, such as business licenses or recent tax returns, as specified by MDHHS.
  • Keep Records: Maintain copies of this form and any documentation you submit for your records. This can be helpful in case any questions arise about your submission.
  • Seek Assistance: If you are unsure about any part of the form, do not hesitate to reach out to a case manager or a representative from MDHHS. They can provide guidance and ensure you complete the form correctly.


Filling out the DHHS self-employment form can initially seem daunting, but by breaking it down into manageable sections, the process becomes much more straightforward. Remember to provide accurate information, keep thorough records, and seek help when needed. With this guide, you're well-equipped to navigate the form with confidence, ensuring that your self-employment income is reported correctly and efficiently.

For further details, always refer to the official guidelines provided by the Michigan Department of Health and Human Services. Happy filing!

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