Form SFN58394 "Independent Contractor Verification Application" - North Dakota

What Is Form SFN58394?

This is a legal form that was released by the North Dakota Department of Labor and Human Rights - a government authority operating within North Dakota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2013;
  • The latest edition provided by the North Dakota Department of Labor and Human Rights;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form SFN58394 by clicking the link below or browse more documents and templates provided by the North Dakota Department of Labor and Human Rights.

ADVERTISEMENT
ADVERTISEMENT

Download Form SFN58394 "Independent Contractor Verification Application" - North Dakota

Download PDF

Fill PDF online

Rate (4.5 / 5) 44 votes
Page background image
600 E Boulevard Ave Dept 406
INDEPENDENT CONTRACTOR VERIFICATION APPLICATION
Bismarck ND 58505-0340
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
701-328-2660
Fax 701-328-2031
SFN 58394 (10-2013)
ND Toll-Free 1-800-582-8032
TTY: 1-800-366-6888
www.nd.gov/labor
Clear Fields
Name of Worker
Telephone Number
Alternate Telephone Number
Address
City
State
ZIP Code
Name of Firm (or Person) for Whom the Worker Performs Services
Firm's Tax ID Number
Telephone Number
Address
City
State
ZIP Code
1.
a. Describe the firm's business.
b. Describe the work done by the worker.
2. If the work is done under a written agreement between the firm and worker, submit a copy.
a. If the agreement is not in writing, describe the terms and conditions of the work arrangement.
b. If the actual working arrangement differs in any way from the agreement, explain the differences and why they occur.
3.
a. Is the worker trained by the firm?
If yes, how often?
Yes
No
If yes, what kind of training is provided?
b. Is the worker given instructions on how to complete the work?
Yes
No
If yes, list specific examples.
c. Attach samples of any written instructions or procedures.
d. Does the firm have the right to change the methods used by the worker or direct the worker on how to do the work?
Yes
No
If yes, explain.
e. Does the operation of the firm's business require that the worker be supervised or controlled in the performance of the service?
Yes
No
If yes, explain.
600 E Boulevard Ave Dept 406
INDEPENDENT CONTRACTOR VERIFICATION APPLICATION
Bismarck ND 58505-0340
NORTH DAKOTA DEPARTMENT OF LABOR AND HUMAN RIGHTS
701-328-2660
Fax 701-328-2031
SFN 58394 (10-2013)
ND Toll-Free 1-800-582-8032
TTY: 1-800-366-6888
www.nd.gov/labor
Clear Fields
Name of Worker
Telephone Number
Alternate Telephone Number
Address
City
State
ZIP Code
Name of Firm (or Person) for Whom the Worker Performs Services
Firm's Tax ID Number
Telephone Number
Address
City
State
ZIP Code
1.
a. Describe the firm's business.
b. Describe the work done by the worker.
2. If the work is done under a written agreement between the firm and worker, submit a copy.
a. If the agreement is not in writing, describe the terms and conditions of the work arrangement.
b. If the actual working arrangement differs in any way from the agreement, explain the differences and why they occur.
3.
a. Is the worker trained by the firm?
If yes, how often?
Yes
No
If yes, what kind of training is provided?
b. Is the worker given instructions on how to complete the work?
Yes
No
If yes, list specific examples.
c. Attach samples of any written instructions or procedures.
d. Does the firm have the right to change the methods used by the worker or direct the worker on how to do the work?
Yes
No
If yes, explain.
e. Does the operation of the firm's business require that the worker be supervised or controlled in the performance of the service?
Yes
No
If yes, explain.
SFN 58394 (10-2013)
Page 2 of 6
4.
a. The firm has the worker:
Perform and complete a particular job only
Work for an indefinite period of time
Other (Explain):
b. Does the worker report to the firm or its representatives?
If yes, list how often:
Yes
No
For what purpose?
In what manner?
In Person
In Writing
By Telephone
Other (Explain):
Attach copies of any report forms used in reporting to the firm.
c. Does the worker furnish a time record to the firm?
No
Yes - Attach copies of time records
5.
a. State the type and value of tools and equipment furnished by the firm
State the type and value of tools and equipment furnished by the worker
b. State the type and value of supplies and materials furnished by the firm
State the type and value of supplies and materials furnished by the worker
c. What expenses are incurred by the worker in the performance of services for the firm?
Does the firm reimburse the worker for any expenses?
If yes, specify the reimbursed expenses:
Yes
No
6.
a. Will the worker perform the services
b. Can the worker have helpers?
If hired by the worker, is the firm's
If yes, who hires the helpers?
personally?
approval necessary?
Yes
No
Yes
No
Yes
No
Firm
Worker
Are social security taxes and Federal income tax withheld from the helpers' wages?
Who pays the helpers?
Yes
No
Firm
Worker
If yes, who reports and pays these taxes?
Who reports the helpers' incomes to the Internal Revenue Service?
Firm
Worker
Firm
Worker
If the worker pays the helpers, does the firm repay the worker?
Does the worker have any helpers presently?
Yes
No
Yes
No
What services do the helpers perform?
7.
At what location are the services performed?
Firm
Worker
Other (Specify):
8.
a. Type of pay worker receives:
Salary
Commission
Hourly Wage
Piecework
Lump Sum
Other (Specify):
b. Does the firm guarantee a minimum amount of pay to the worker?
c. Does the firm allow the worker a drawing account or advances
against pay?
Yes
No
Yes
No
If yes, is the worker paid such advances on a
d. How does the worker repay such advances?
regular basis?
Yes
No
SFN 58394 (10-2013)
Page 3 of 6
9.
a. Is the worker eligible for any benefits such as annual/sick leave, retirement,
If yes, specify:
insurance, etc.?
Yes
No
b. Does the firm carry workers compensation insurance on the worker?
c. Does the firm deduct social security tax from amounts paid the worker?
Yes
No
Yes
No
d. Does the firm deduct Federal income taxes from amounts paid the worker?
Yes
No
e. How does the firm report the worker's income to the Internal Revenue Service?
Form W-2
Form 1099
Does Not Report
Other (Specify):
f. Does the firm bond the worker?
Yes
No
10.
a. Is the worker required to work a
If yes, how many?
When?
Yes
No
certain number of hours per day?
b. Is the worker required to follow a routine or schedule established by the firm?
Yes
No
If yes, what is the routine or schedule?
c. Does the worker perform similar services for others?
If yes, are these services performed on a daily basis for other firms?
Yes
No
Yes
No
Percentage of time spent in performing these services for:
This firm:
Other firms:
Does the firm have priority on the worker's time?
If no, please explain.
Yes
No
d. Is the worker prohibited from competing with the firm either while performing services or during any later period?
Yes
No
If yes, please explain.
11.
a. Can the firm discharge the worker any time
If no, please explain.
without incurring a liability?
Yes
No
b. Can the worker terminate the services at any
If no, please explain.
time without incurring a liability?
Yes
No
12.
a. Does the worker perform services for the firm under:
The Firm's Business Name
The Worker's Business Name
Other (Specify):
State Business Name
b. Does the worker advertise or maintain a business listing in the telephone directory, in a trade journal, on the internet, etc?
Yes
No
If yes, specify.
c. Does the worker represent himself or herself to the public as being in business to perform the same or similar services?
Yes
No
If yes, specify.
d. Does the worker have his or her own shop or office?
If yes, where?
Yes
No
e. Does the firm represent the worker as an employee of the firm to its customers?
Yes
No
f. How did the firm learn of the worker's services?
SFN 58394 (10-2013)
Page 4 of 6
13.
Is a license necessary for the kind of work performed?
If yes, what type of license is required?
Yes
No
By whom is the license issued?
By whom is the license fee paid?
14.
Does the worker have a financial investment in a business (i.e. tools, vehicles, building, employees, etc.), related to the services the worker performs?
Yes
No
If yes, specify and provide amounts of the investment.
15.
Can the worker incur a loss in the performance of the service for the firm?
Yes
No
If yes, how?
16.
During the past 5 years, has any other government agency ruled on the employee/independent contractor status of any of the firm's workers?
Yes
No
If yes, please explain the circumstances and findings. Also, please attach a copy of the ruling, if available.
17.
Does the worker assemble or process a product at home or away from the firm's place of business?
Yes
No
If yes, answer a, b, and c below:
a. Who furnishes materials or goods used by the worker?
b. Is the worker furnished a pattern or given instructions to follow in making the product?
Yes
No
Firm
Worker
c. Is the worker required to return the furnished product to the firm or to someone designated by the firm?
18.
Does the worker perform sales?
Yes
No If yes, answer remaining questions:
a. Are leads to prospective customers furnished by the firm?
Yes
No
b. Is the worker required to pursue or report on leads?
Yes
No
c. Is the worker required to adhere to prices, terms, and conditions of the sale established by the firm?
Yes
No
d. Are orders submitted to and subject to approval by the firm?
Yes
No
e. Is the worker expected to attend sales meetings?
If yes, is the worker subject to any kind of penalty for failing to attend?
Yes
No
Yes
No
f. Does the firm assign a specific territory to the worker?
Yes
No
g. Whom does the customer pay?
If worker, does the worker remit the total amount to the firm?
Yes
No
Firm
Worker
h. Does the worker sell a consumer product in a home or establishment other than a permanent retail establishment?
Yes
No
i. List the products and/or services distributed by the worker. If more than one type of product and/or service is distributed, specify the principal one.
SFN 58394 (10-2013)
Page 5 of 6
18. (continued)
j. Did the worker pay the firm or person for the privilege of serving customers on the route or in the territory?
Yes
No
If yes, how much did the worker pay?
What factors were considered in determining the value of the route or territory?
k. How are new customers obtained by the worker? Explain fully, showing whether the new customers called the firm for service, were solicited by the
worker, or both.
l. Does the worker sell life insurance?
Yes
No
m. Is the worker a traveling salesperson or city salesperson?
Yes
No
If yes, specify from whom the worker principally solicits orders on behalf of the firm?
If the worker solicits orders from wholesalers, retailers, contractors, or operators of hotels, restaurants,
or other similar establishments, specify the percentage of the worker's time spent in such solicitation.
n. Merchandise is purchased:
By the customers for resale
For use in the business operations
If used by the customers in their business operations, describe the merchandise and whether it is equipment installed on their premises or is a consumable
supply.
19. Explain below or attach a detailed explanation for any reason why you believe the worker is either an independent contractor or an employee of the firm.
Continue on next page
Page of 6