Revised 5/2013 Instructions
PERSONAL WAGE RECORD
BHSF Wages
Purpose:
BHSF Form Wages is used at initial application only for persons who are self-
employed with no other verification of earnings, OR to identify incidental
employment for persons working at odd jobs.
Preparation:
This form is prepared as an original and is photocopied upon completion.
Complete the paper form, or use the fillable form available on the “BHSF Forms”
link on the online application homepage.
Enter the applicant’s name and SSN.
Leave Case ID# blank.
The return date for the applicant is two weeks from the date of the interview.
Disposition:
BHSF Form Wages is given to each applicant who is self-employed, or working
at odd jobs and has no other proof of earnings. This form may be given to an
applicant who is incidentally employed for maintaining wage records on a
continuing basis.
Give the original BHSF Form Wages to the applicant and forward the copy to the
appropriate Medicaid Office daily. Inform the applicant to return the completed original
form to the appropriate Medicaid Office within two weeks from the date of the
interview.