Independent Contractor Qualification
Directions:
This is your application for certification of qualifications to be paid as an Independent Contractor. In doing so, you should be aware of the following information: 1. The recipient of your services, ___________., will make no tax or benefit deductions from your paycheck. Payments will be made based upon a schedule established between you and ___________, which may or may not follow its regular payment plan for its employees. 2. Instead of receiving a from W-2 for your earnings, you will instead be issued a Form 1099. ___________ has no responsibility for making any tax deductions, or paying for any taxes which you owe. 3. You are not entitled to any benefits offered by ___________ to its employees. You are operating your own business, and as such are responsible for all expenses which you incur during the course of executing this work. 4. Specifically you agree that ___________ has no liability for Workmen’s Compensation or any disability you may suffer as a result of performance of work for the company. Put an X in the column that correctly answers each question. In the event that any Question, other than Questions 16 is answered “Yes,” or Item 16 is answered “No,” you have failed to qualify as an Independent contractor for ___________. No Yes Questions 1. Are you required to comply with instructions about when, where and how the work is done? 2. Are you provided training that would enable you to perform your work for the recipient of your services, in a particular method or manner? 3. Are the services provided you an essential part of the ___________'s regular operations? 4. Must the services be rendered personally by you? 5. Does___________, supervise, or pay assistants to help the you perform your work? 6. Is there a continuing relationship between you and the person or organization, for whom the services are performed? 7. Does ___________ set the your work schedule? 8. Are you required to devote your full time to ___________? 9. Is the work performed at the place of business of ___________, or at specific places set by the company?
10. Does ___________ direct the order in which the work must be done? 11. Are you required to submit regular oral or written reports? 12. Is the method of payment hourly, weekly, monthly (as opposed to an agreement for each project?) 13. Are your business and/or traveling expenses reimbursed? 14. Does ___________ furnish tools and materials which you use? 15. Have you failed to invest in equipment or facilities used to provide the services? 16. Do the terms and conditions of your work put you in a position of realizing either a profit or loss on the work? 17. Does you perform services exclusively for___________, rather than working for a number of companies at the same time? 18. Do you, in fact, make your services regularly available to the general public? 19. Are you subject to dismissal for reasons other than nonperformance of the contract specifications? 20. Can you terminate your relationship to ___________ without incurring a liability for failure to complete the job? I declare the information I have provided above is true to the best of my information and belief. By my signature below, I acknowledge that I understand the information provided, and that, should___________ suffer any liability as a result of incorrect information, as set forth by my answers to the above questions, I may be financially responsible for such liabilities. _________________________ Signature ________________________ Name Printed ________________________ Dated ________________________ Social Security or EIN Number