REQUEST FOR INDEPENDENT CONTRACTOR (IC) STATUS
Use this form to obtain approval from the Tax Manager in Financial Accounting PRIOR TO entering into
an agreement for services to be performed as an independent contractor.
***Click on the INSTRUCTIONS tab at bottom for guidance***
Click here to clear work area
and start a new form. Enter requested information in the fields below:
Business Name (if applicable) Enter complete
Home Address (Street, City, State, Zip) address on one line
Social Security Number
Federal Tax ID Number (if applicable)
Click on buttons to answer the following questions. Where applicable, enter requested info in the fields below:
University Employee (or former employee within the last 18 months?)
Related to University Employee?
If YES, employee's name/relationship:
U.S. Citizen or Permanent Resident (green-card holder)?
If NO, country of citizenship:
DATES AND DURATION OF SERVICE
Indicate the beginning and ending dates of the time frame for which you are requesting IC approval (maximum 12 months).
Dates of service to be rendered FROM: ( m/d/yy )
TO: ( m/d/yy )
Indicate how often services will be rendered by clicking on one of the following choice buttons.
For "Ongoing" or "Other", indicate the requested information in the fields below:
(indicate # hrs per week)
METHOD OF PAYMENT
Click on one of the following choices. For "Installments" or "Other", input explanation in appropriate field below:
(specify # & frequency)
DESCRIPTION AND LOCATION OF SERVICES
Describe the services to be performed: Enter below. (Tab to Leftmost Column) Do not type more than 3 lines of text.
Where will the work be done? Enter below. (Tab to Leftmost Column) Do not type more than 3 lines of text.
ALL OF THE FOLLOWING QUESTIONS MUST BE ANSWERED
Click on the answer for each of the following six questions:
1. Will the IC provide his/her own tools, materials, equipment, etc.? 1
2. Will the IC be working on a fixed schedule specified by UA? 2
3. Will the IC receive training from UA in order to do the work? 3
4. Will the details of the work be directed or supervised by UA personnel? 4
5. Will the IC supervise UA personnel? 5
6. Does the IC perform this type of service for others besides UA? 6
Enter requested information in the fields below:
Department Contact for Questions:
Contact Phone Number:
Campus Mail Box Number:
REQUEST FOR INDEPENDENT CONTRACTOR STATUS
Form must be approved prior to engaging the services of an independent contractor (IC).
Date August 1, 2010
I. VENDOR INFORMATION
Social Security # Federal Tax ID#
University employee (or former employee within the last 18 months?)
Related to University employee? If YES, explain:
U. S. Citizen or Permanent Resident (green-card holder)?
If NO, country of citizenship:
II. DESCRIPTION OF SERVICE
Date(s) of service to be rendered: From to
Duration of service:
Method of payment:
Describe the services to be performed:
Where will the work be done?
1. Will the IC provide his/her own tools, materials, equipment, etc. to do the work?
2. Will the IC be working on a fixed schedule specified by UA?
3. Will the IC receive training from UA in order to do the work?
4. Will the details of the work be directed or supervised by UA personnel?
5. Will the IC supervise UA personnel?
6. Does the IC perform this type of service for others besides UA?
III. DEPARTMENT INFORMATION
Department Official Requesting Approval: FOAPAL:
DEPARTMENT CONTACT FOR QUESTIONS CONCERNING THIS REQUEST:
Name Phone FAX Box
IV. FINANCIAL ACCOUNTING USE
Tax Manager or designee Date
Not Approved - This position does not qualify for independent contractor status. The securing of services
for this individual must follow University hiring procedures. Please contact your Human Resource
Partner for assistance.
Not Approved - The above individual is currently on University payroll. Payment to this individual must be
processed on a supplemental Personnel Action form.
Form IC (revised 7/06)
INSTRUCTIONS FOR INDEPENDENT CONTRACTOR (IC) APPROVAL:
Complete the IC form when you anticipate obtaining services from someone to be paid outside the payroll
Click on the INPUT tab at bottom and enter all requested information on the INPUT page. Then click on the
PRINT tab at bottom to switch to the PRINT page. Here you can review your completed form and use the Print
icon to print a hard copy.
If input does not transfer correctly to the PRINT page, be sure your Macro Security Level is set on Medium. (Go
into "Tools", "Macro", "Security" and select "Medium" security level.) When opening worksheets, you should
get a choice box and select "Enable Macros". This will allow the macros to run to transfer the data from INPUT
to PRINT page.
Forward the completed form to Michelle L'Etang, Tax Manager, Financial Accounting.
You may send by any of the following options:
Fax the form to 8-7282 (direct line in the Tax Office)
Send as an e-mail attachment to email@example.com
Send by campus mail to Box 870136
Deliver to Room 326 Rose front desk
When you receive the signed form back, keep copies to attach to EACH Miscellaneous Disbursement Voucher
(MDV) for payment. This is the department's responsibility. Do not attach an unsigned IC form to an MDV that
you are submitting to be paid. Get the approval signature first.
Once IC approval has been received, you may proceed with the Professional Service Agreement (PSA).
NOTE: While we are allowed to use faxes/copies on the IC form, the MDV and PSA forms must have
For questions regarding the completion of this form or the approval process, contact Michelle L'Etang, Tax
Manager, at 8-2963 or firstname.lastname@example.org.