DEPARTMENT OF HEALTH SERVICES Division of Medicaid Services F-01985 (02/2017)	STATE OF WISCONSIN
Self-Employment Income Worksheet Personal Capital Gains or losses (Schedule D)
Name – Self-Employed Individual	Case Number	Tax Year Filing
Name – Worker	Worker’s ID	Date Completed
INSTRUCTIONS A single worksheet should be used to calculate either a gain or a loss but not both. For the table below, negative numbers (losses) should be enclosed in parentheses. For example, ($100.00) indicates a $100 loss rather than a $100 gain. If a line on the Schedule D is left blank, enter a zero on this worksheet. All completed worksheets must be retained in the individual’s case record.
SCHEDULE D (CAPITAL GAINS AND LOSSES) Complete only section A or B below but not both.
A. Income Gain	Schedule D	FoodShare	BadgerCare Plus Modified Adjusted Gross Income	Elderly, Blind, or Disabled Medicaid	CWW Unearned Income Page Field (PC-Personal Capital Gains Income Type)
1	Ordinary gain	Line 16	N/A	N/A	N/A
2	Divide line 1 by 12 months. (This is the total countable income maintenance amount.)	N/A	N/A	N/A	Gross Income Amount (in the Details section)
B. Income Loss	Schedule D	FoodShare	BadgerCare Plus Modified Adjusted Gross Income	Elderly, Blind, or Disabled Medicaid	CWW Unearned Income Page Fields (PC-Personal Capital Gains Income Type)
1	Ordinary loss	Line 21	N/A	N/A	N/A
2	Divide line 1 by 12 months. (This is the total countable income maintenance amount.)	N/A	N/A	N/A	Monthly Personal Capital Losses (in the Disregards, Expenses and Losses section)
IMPORTANT INFORMATION The following are recommended best practices: If a Net Operating Loss (NOL) is indicated on line 21 of Form 1040, a separate sequence of the Self-Employment page in CWW must be created for the NOL. On the separate sequence, a zero should be entered in the Gross Income field, and the NOL should be entered in the Gross Expenses and Depreciation Amount fields. If Form 1040 is available, the reported income on this worksheet and on Form 1040 should be compared.