"Independent Contractor Form"

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Independent Contractor Form
Name ________________________________________
SSN ______________________
1. Is the worker given training by the State Agency?
_____ YES
_____ NO
1.a. If “YES”, please describe.
2. Is the worker given instruction the way the work is to be done?
_____ YES
_____ NO
3. Does the State Agency have the right to change the methods used
_____ YES
_____ NO
by worker or direct that person on how to do the work?
4. Is the worker required to follow a routine or a schedule established by the State Agency?
_____ YES
_____ NO
5. How often does the worker report to the State Agency?
5.a. What method is used by the worker to report to the State Agency?
5.b. For what reasons does the worker report to the State Agency?
6. How does the worker report his/her time to the State Agency?
7. What kind of tools/equipment/materials/supplies are provided by:
THE STATE AGENCY:
THE WORKER:
8. What kind of expenses are incurred by the worker in the performance of services
for the State Agency?
8.a. Is the worker reimbursed by the State Agency for any of these expenses?
_____ YES
_____ NO
If “YES”, please explain:
9. Will the worker perform the service personally?
_____ YES
_____ NO
Independent Contractor Form
Name ________________________________________
SSN ______________________
1. Is the worker given training by the State Agency?
_____ YES
_____ NO
1.a. If “YES”, please describe.
2. Is the worker given instruction the way the work is to be done?
_____ YES
_____ NO
3. Does the State Agency have the right to change the methods used
_____ YES
_____ NO
by worker or direct that person on how to do the work?
4. Is the worker required to follow a routine or a schedule established by the State Agency?
_____ YES
_____ NO
5. How often does the worker report to the State Agency?
5.a. What method is used by the worker to report to the State Agency?
5.b. For what reasons does the worker report to the State Agency?
6. How does the worker report his/her time to the State Agency?
7. What kind of tools/equipment/materials/supplies are provided by:
THE STATE AGENCY:
THE WORKER:
8. What kind of expenses are incurred by the worker in the performance of services
for the State Agency?
8.a. Is the worker reimbursed by the State Agency for any of these expenses?
_____ YES
_____ NO
If “YES”, please explain:
9. Will the worker perform the service personally?
_____ YES
_____ NO
10. At what location are the services performed?
_____ State Agency’ s
_____ Worker’ s _____ Other (Specify)
11. What type of pay does the work receive?
_____ Salary _____ Commission
_____Hourly wage _____Piecework _____ Lump Sum _____Other (Specify)
12. Does the State Agency guarantee a minimum amount of pay to work?
_____ YES
_____ NO
13. Approximately how many hours a day does the worker perform the service for the State Agency? ___________________
14. Does the worker perform similar services for others?
_____ YES
_____ NO
15. What is the percentage of time spent by the worker in performing services?
This State Agency _____%
Other State Agencies _____%
Other Firms _____%
16. Can the State Agency discharge the worker at any time without incurring a liability?
_____ YES
_____ NO
17. Can the worker terminate the services at any time without incurring a liability?
_____ YES
_____ NO
18. Does the worker advertise or maintain a business listing in the telephone directory/trade journal? _____ YES
_____ NO
19. Does the worker represent himself or herself to the public as being in business to perform the same or similar services?
_____ YES
_____ NO
20. Does the worker have his or her own shop or office?
_____ YES
_____ NO
20a. If ”YES”, where?_____________________________________________________
21. Does the worker have a financial investment in a business related to the services performed? _____ YES
_____ NO
22. Can the worker incur a loss in the performance of the service for the State Agency?
_____ YES
_____ NO
Under penalties of perjury, I declare that I have examined this request, including accompanying documents, and to the best of my
knowledge and belief, the facts presented are true, correct, and complete.
SIGNATURE__________________________________________
DATE ______________
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