The Florida KidCare Self-Employment Form is a one-page worksheet that each self-employed adult in your household fills out so the state can set your children’s premium. It asks for one recent month of gross business income and itemized expenses, a signature, and your Family Account Number on every page. You download it from the Florida KidCare Parent Portal, then submit it by online upload, fax, email, or mail.
Who Has to File One
Anyone in the household who earns money outside a traditional W-2 job needs their own form. That covers sole proprietors, independent contractors, gig workers, freelancers, and business partners. Florida KidCare is income-based, so without this worksheet reviewers have no way to verify what a self-employed applicant actually brings in.1Florida KidCare. Requirements
You submit it when you first apply and again at annual renewal. If two adults in the home are both self-employed, each one completes a separate form.
What to Have Ready
Pull these together before you open the PDF:
- Your Family Account Number, from the Parent Portal or any prior Florida KidCare letter.
- Gross income for the most recent month — total revenue before taxes or deductions.
- Expense records for that same month: receipts, bank statements, or bookkeeping entries.
- Last year’s federal tax return, which Florida KidCare may ask for as backup. Sole proprietors should expect to be asked for Schedule C.2Internal Revenue Service. About Schedule C (Form 1040), Profit or Loss from Business (Sole Proprietorship)
If you’re filling in a paper copy, use blue or black ink.3Florida KidCare Parent Portal. Self-Employment Form
Filling In the Form
Identification and Gross Income
At the top, write the name of the self-employed household member and the business name. Then enter total self-employment gross income — before taxes — for the most recent month. Include cash, digital transfers, and any other revenue the business took in. This field is required.3Florida KidCare Parent Portal. Self-Employment Form
Allowable Business Expenses
Below the income line are 20 expense categories. Enter the dollar amount spent in each one during the same month:
- Advertising
- Business license
- Business telephone and utilities
- Business transportation (delivering products or traveling to client sites, not your daily commute)
- Raw materials, farm supplies, feed, and stock
- Employee benefits
- Employer’s share of FICA
- Employee wages
- Interest on a farm or business loan
- Insurance on property and equipment
- IRS allowable business expense (a catch-all for legitimate costs that don’t fit elsewhere)
- Legal fees for the business
- Meals and equipment for children in day care (day care operators only)
- Motor vehicle operating costs, such as gas and oil
- Office supplies and tools
- Postage
- Property taxes on income-producing property
- Rent for building, land, or equipment
- Repairs and maintenance on equipment or business property
- Travel and lodging away from home
- Tax preparation fee for the business
Add the lines up and write the sum in the “Total Business Expenses for the Most Recent Month” field. That total is required.3Florida KidCare Parent Portal. Self-Employment Form
Signature
Sign and date at the bottom. The certification reads: “I confirm, under punishment by law, that the information provided on this Self-Employment Statement is true.” Both the signature and the date are required, and an unsigned form will be returned to you.3Florida KidCare Parent Portal. Self-Employment Form
When the Month Isn’t Typical
Seasonal businesses — landscaping, tourism, tax preparation — can post wildly different numbers depending on when the form is completed. If the most recent month was unusually high or low, attach a separate sheet explaining the difference. Put your name and Family Account Number on that sheet, and describe what a typical month looks like and why this one wasn’t.3Florida KidCare Parent Portal. Self-Employment Form Without that note, a reviewer could use an unrepresentative month to set your premium.
How to Send It In
Florida KidCare accepts the completed form four ways. Whichever you pick, write your Family Account Number on every page.
- Online upload. Log in at portal.floridakidcare.org, click “Document uploads,” then “Upload a new document.” Pick the reason and document type. Files must be under 10 MB, and the portal accepts.pdf,.jpg,.jpeg,.png,.gif, and.tif. Password-protected or encrypted files won’t go through.4Florida KidCare. FAQs – Florida KidCare
- Fax to 1-866-867-0054 (toll-free).3Florida KidCare Parent Portal. Self-Employment Form
- Email to contactus@healthykids.org. The attachment must be under 10 MB and in.pdf,.jpeg,.png,.tif, or.gif.3Florida KidCare Parent Portal. Self-Employment Form
- Mail to Florida KidCare, P.O. Box 591, Tallahassee, FL 32302-0591.3Florida KidCare Parent Portal. Self-Employment Form
For questions, call 1-888-540-KIDS (5437), Monday through Friday, 7:30 a.m. to 7:30 p.m. Eastern.5Florida KidCare. Contact Us – Florida KidCare
After You Submit
Once Florida KidCare has a complete application with all required documents, a decision letter typically arrives within a couple of weeks. If reviewers need to request more information, the process can take up to six weeks.4Florida KidCare. FAQs – Florida KidCare When documents are missing, you have 45 days from the request date to send them in; miss that window and the application can be closed.
You can track your case in the Parent Portal, which shows pending status, outstanding document requests, and the program your child is placed in once a decision is made.
Why the Numbers You Report Matter
Florida KidCare uses household adjusted gross income, household size, and each child’s age to assign a premium tier against Federal Poverty Level guidelines.1Florida KidCare. Requirements Based on the 2025 guidelines, the tiers are:
- Up to 133% of FPL: $0 per month (Medicaid).
- 133.01% to 158% of FPL: $15 per month for all eligible children in the household.
- 158.01% to 200% of FPL: $20 per month for all eligible children.
- Over 200% of FPL: full-pay plan — $248.21 per child per month (MediKids) or $276 per child per month with dental (Florida Healthy Kids).6Florida KidCare. Cost
The gap between $15 or $20 for the whole household and $248 or $276 per child is why this form is worth getting right. If you skip expense lines you’re entitled to claim, or omit the form entirely, the state may default your children to the full-pay tier because it cannot verify that income falls below 200% of FPL.7Florida KidCare. 2025 General Annual Income Guidelines
Renewal
Coverage runs a year at a time. About two months before your renewal date, a notification posts to the Parent Portal asking you to confirm household information.8Florida KidCare. Renew – Florida KidCare If you’re still self-employed, plan on submitting a fresh Self-Employment Form with updated figures for the most recent month, and be ready to provide bank statements or tax returns if the state can’t verify your income through electronic data matching. Renewing through the portal is the fastest route, and your premium tier can shift up or down if income or household size has changed.