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					                                   VIRGINIA INSTITUTE OF MARINE SCIENCE
                                                  College of William & Mary • School of Marine Science

                                                      Certified Work Statement
                                                            PLEASE PRINT ALL REQUESTED INFORMATION

Name:                                                                     Date:                                October 23, 2012
Social Security Number or Federal Employer I.D.:
Complete Home Address:



Telephone Number:
                                                    Type of Work (provide a complete description)




Department for whom work is to be performed:
Date Work to be Initiated:                          Scheduled Date of Completion:
Contract Amount:                                    Payment Terms:
                                     Independent Contractor Certification Statement
I certify that I have been contracted to perform the above-stated work. I further certify that I have been engaged as an independent contractor* to render the above-
referenced services to the Virginia Institute of Marine Science, College of William & Mary. The Institute does not directly control the hours or means and methods
for my accomplishment of the results. I am not currently employed, and have not been employed during the current calendar year, in any capacity, as an
employee of the Commonwealth of Virginia, which includes all of its agencies. I understand that the College is required by the Internal Revenue Service to
report, via form 1099, all payments exceeding $600 made to me during this calendar year.



          Printed Name of Independent Contractor                                   Independent Contractor Signature                                  Date


                                                    Departmental Certification and Approval for Payment

I certify that the above-named individual has been engaged as an independent contractor* to render services to the Virginia Institute of Marine Sciences, College of
William & Mary, that I/we did not directly control the hours or means and methods for accomplishment of the work for which he/she was hired. I further certify
that, to the best of my knowledge, the individual is not currently an employee of the Commonwealth of Virginia. This statement is approved for payment.
(Payment for fish samples and fishery services requires invoice (per procedure) approval by QA/QC officer, and business office approval below.)



          Printed Name of Authorizing Person                                       Authorized Signature (in ink)                                     Date




          Banner Index Number/Account                  Business Office Approval (for purchase of fish samples and/or fishery services only)

              DO NOT WRITE BELOW THIS LINE — HUMAN RESOURCES/PAYROLL USE ONLY
Human Resources/Payroll Certification:
   No                               Yes                     Type
  Date                           Initials
* If the individual was paid as an employee at any time during the current calendar year, he/she must be paid through the payroll process
REVISED 08/15/2000                    THIS FORM MUST BE COMPLETED AND ATTACHED TO A VIMS PURCHASE ORDER REQUEST FORM.
(IF USED AS A CONTRACTING DOCUMENT TO PROCURE FISH SAMPLES AND/OR FISHERY SERVICES: INCLUDE DESCRIPTION OF COMPENSATION, AND NAMES OF QA/QC
OFFICERS UNDER "TYPE OF WORK"; SECURE BUSINESS OFFICE APPROVAL -- NO PURCHASE ORDER NECESSARY.)

				
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