WESTERN CAROLINA UNIVERSITY Check Distribution Details
Date Check Needed:
STANDARD AGREEMENT FOR INDEPENDENT CONTRACTOR Date of Event:
(Note: State law prohibits payment prior to completion of services.)
The undersigned Independent Contractor (hereinafter "IC") and Western Mail to Independent Contractor
Carolina University (hereinafter "University) agree to the following terms and Check will be picked up by:
conditions for the performance of certain tasks as described below:
1. IC is identified as follows:
Type of Entity (check all that apply):
Sole Proprietorship Government Entity (State or Federal) Corporation Attorney
Partnership Provider of medical & health services Non-Profit Other - Specify _______________
LLC (Enter LLC Tax Classification: D = Disregarded Entity; C = Corp.; P = Partnership: _______ )
Principal Place of Business:
Permanent Address: Business Telephone:
If any Permanent part of your business is located in North Carolina, and not listed as "Principal place of business" in the previous section, please
provide this address also:
Social Security Number: or Employer ID #: -
North Carolina Secretary of State Certificate of Authority ID#, if out-of-state corporation or LLC :
2. Description of tasks to be performed by IC:
3. Will any revenues be generated in connection with event? (If yes, please complete a and b below.)
a. Please detail source(s) of revenue (Ticket sales, sponsorships, private gifts, etc.)
b. Fund # in which proceeds will be deposited:
May be subject to withholding if payment or total
4. Total Price: Subject to 4% NC Withholding (Yes or No) payments for the year exceeds $1500 and is paid to
an out-of state individual or entity for entertainment,
a speech, or performance.
5. Payment Detail: Accountable Officer Approval
Fund & Account: Amount: (Printed Name) (Signature)
*If more accounts are required, please use a separate sheet to list them.
6. Official University Representative (Departmental): Phone No.
7. Indicate any Riders which are to be made part of this agreement:
Additional Agreement Provisions:
Please send two copies of this first page when using in conjunction with an agency, entertainer, or other entities contract.
8. This agreement begins upon execution by both parties and shall end on unless terminated as provided
9. The Payment to a non-resident IC may be subject to 4% backup withholding in accordance with North Carolina General Statute
10. It is understood that the IC executes this agreement as an Independent Contractor and is not an employee of the University, and
that IC shall have the exclusive control over the means, methods and details of fulfilling its obligation under this contract.
11. IC agrees to perform and discharge all obligations of an Independent Contractor under any and all laws, whether existing or in
the future, in any way pertaining to the tasks hereunder, including but not limited to Social Security laws, Workman's
Compensation Insurance, income taxes, State Employment Insurance, taxes or contributions, Public Liability Insurance; and IC
will hold University harmless against all such laws as well as against all union claims for welfare payments. No payroll tax shall
be withheld or paid by University on behalf of IC or the employees of IC. No Worker's Compensation Insurance shall be
obtained by University concerning IC or IC's employees.
12. The parties agree that this agreement was entered into in the State of North Carolina and that the laws of North Carolina shall
govern this contract as to interpretation and performance. It is further agreed that the place of this contract, its situs and forum,
will be Jackson County, North Carolina, and in said county and state will all mattes, whether sounding in contract or tort relating
to the validity, construction, interpretation and enforcement of this contract, be determined.
13. The parties agree that the agreed price for the engagement as set forth in paragraph 4 includes travel expenses, accommodation
expenses and any and all other expenses, costs and remuneration the parties have agreed to unless otherwise provided for in
14. The University may terminate this contract at any time by notice in writing from the University to the Contractor. In that event,
all finished or unfinished documents and other materials shall, at the option of the University, become the University's property.
If the contract is terminated by the University, as provided herein, the Contractor will be paid in an amount which bears the same
ratio to the total compensation as does the service actually performed to total service set forth in the Agreement.
Notwithstanding, the IC shall not be relieved of liability to the University for damages sustained by the University by virtue of
any breach of this agreement or failure to perform, and the University may withhold payment to the IC for the purpose of set-off
until such time as the exact amount of damages due the University from such breach or failure can be determined.
15. This contract will not be used for advertising by IC without prior approval of the University.
16. This contract has been entered into compliance with state and federal antitrust laws.
17. Neither party shall be responsible to the other for any losses resulting from the failure to perform any terms or provisions of this
Agreement if the party's failure to perform is attributable to war, riot or other disorder, strike or other work stoppage; fire; flood;
storm; illness; or any other act not within the control of the party whose performance is interfered with, and which, by reasonable
diligence, such party is unable to prevent.
INDEPENDENT CONTRACTOR WESTERN CAROLINA UNIVERSITY
(Print or type name of IC)
Agreed by (IC or Authorized Signature) Agreed by Vice Chancellor
WESTERN CAROLINA UNIVERSITY
DETERMINATION OF ELIGIBILITY FOR INDEPENDENT CONTRACTOR
Payee Name Taxpayer Identification Number
I. Eligibility No Yes
1. Is the payee a non-resident alien? (if no, go to question 2.) Go to #2 Go to a.
a. If yes, will the payee be here on an A-1, F-1, G-1, J-1, M-1, Q-1, or TN Visa?
**If 1a is yes, see last page of form for requirements to be met before payment
can be made and complete the rest of this form.
**If 1a is no, stop here. The individual may not be contracted with or paid
compensation for any type of service.
2. Is the payee an employee of any agency of the State of North Carolina (see list of
agencies on the last page of this form)? If yes, you must STOP here. The individual
cannot be paid as an independent contractor. He/she must be paid through dual
employment as provided in the State Budget Manual.
II. Determination of Independent Work Status
(A yes answer indicates an employer/employee relationship and payment must be made through payroll.)
1. Is the individual working exclusively for Western Carolina University?
2. Are the services of the individual integrated into the organization? For example, are you hiring
someone to teach a credit course? (Normally performed by WCU employees?)
3. Is the WCU dept. providing long-term assistance to the individual such as additional personnel
support, supplies, equipment, etc?
4. Is the WCU dept. providing on-going training and direction concerning how to complete the task?
5. Does the prospective payee/independent contractor report to a WCU staff member who has the
right to change HOW the individual does their work?
6. Is there a regular on-going relationship with the prospective payee/independent contractor?
For example, are you hiring the individual for more than a one time task?
7. Is the prospective payee/independent contractor using experience or expertise gained as a
previous employee of WCU to provide the independent contractor services?
8. Can the independent contractor quit prior to completion of the project without incurring any
9. Will payment to the payee include a separate reimbursement of travel expenses?
I certify that the information provided above is correct:
Payee Signature (must be payee named above) Phone # Date