Form SS-8 Application for Worker Status Determination

DETERMINING INDEPENDENT CONTRACTOR STATUS

(Based on IRS Form SS-8)

1. Describe the firm’s business.

2. Describe the work done by the worker.

3. If the work is done under a written agreement between the firm and the worker, attach a copy.

4. If the agreement is not in writing, describe the terms and conditions of the work agreement.

5. If the actual working arrangement differs in any way from the agreement, explain the differences and why they occur.

6. Is the worker given training by the firm? Yes No

• If yes, what kind?

• How often?

7. Is the worker given instructions in the way the work is to be done? Yes No

• If yes, give specific examples.

8. Attach samples of any written instructions or procedures.

9. Does the firm have the right to change the methods used by the worker or direct that person on how to do the work? Yes No

• Explain your answer.

10. Does the operation of the firm’s business require that the worker be supervised or controlled in the performance of the service? Yes No

• Explain your answer.

11. The firm engages the worker:

12. Is the worker required to follow a routine or a schedule established by the firm? Yes No

• If yes, what is the routine or schedule?

13. Does the worker report to the firm or its representative? Yes No

• If yes, how often?

• For what purpose?

• In what manner (in person, in writing, by telephone, etc.)?

• Attach copies of any report forms used in reporting to the firm.

14. Does the worker furnish a time record to the firm? Yes No

15. State the kind and value of tools, equipment, supplies, and materials furnished by:

• The firm:

• The worker:

16. What expenses are incurred by the worker in the performance of services for the firm?

17. Does the firm reimburse the worker for any expenses? Yes No

• If yes, specify the reimbursed expenses.

18. Will the worker perform the services personally? Yes No

19. Does the worker have helpers? Yes No

• If yes, who hired the helpers? Firm Worker

• If the helpers are hired by the worker, is the firm’s approval necessary? Yes No

• Who pays the helpers? Firm Worker

• If the worker pays the helpers, does the firm repay the worker? Yes No

• Are Social Security and Medicare taxes and Federal income tax withheld from the helpers’ pay? Yes No

• If yes, who reports and pays these taxes? Firm Worker

• Who reports the helpers’ earnings to the Internal Revenue Service? Firm Worker

• What services do the helpers perform?

20. At what location are the services performed? Firm’s Worker’s Other (specify)

21. Type of pay worker receives:

22. Does the firm guarantee a minimum amount of pay to the worker? Yes No

23. Does the firm allow the worker a drawing account or advances against pay? Yes No

• If yes, is the worker paid such advances on a regular basis?

24. How does the worker pay such advances?

25. Is the worker eligible for a pension, bonus, paid vacations, sick pay, etc.? Yes No

• If yes, specify.

26. Does the firm carry Workers’ Compensation insurance on the worker? Yes No

27. Does the firm withhold Social Security and Medicare taxes from amounts paid the worker? Yes No

28. Does the firm withhold Federal income tax from amounts paid the worker? Yes No

29. How does the firm report the worker’s earnings to the Internal Revenue Service?

• Attach a copy.

30. Does the firm bond the worker? Yes No

31. Approximately how many hours a day does the worker perform services for the firm?

32. Does the firm set hours of work for the worker? Yes No

• If yes, what are the worker’s set hours?

33. Does the worker perform similar services for others? Yes No

• If yes, are these services performed on a daily basis for other firms?

• Percentage of time spent in performing these services.

• Does the firm have priority on the worker’s time? Yes No

• If no, explain.

34. Is the worker prohibited from competing with the firm either while performing services or during any later period? Yes No

35. Can the firm discharge the worker at any time without incurring a liability? Yes No

36. Can the worker terminate the services at any time without incurring a liability? Yes No

• If no, explain.

37. Does the worker perform services for the firm under:

38. Does the worker advertise or maintain a business listing in the telephone directory, a trade journal, etc.? Yes No

• If yes, specify.

39. Does the worker represent him/herself to the public as being in business to perform the same or similar services? Yes No

• If yes, how?

40. Does the worker have his/her own shop or office? Yes No

• If yes, where?

41. Does the firm represent the worker as an employee of the firm to its customers? Yes No

• If no, how is the worker represented?

42. How did the firm learn of the worker’s services?

43. Is a license necessary for the work? Yes No

• If yes, what kind of license is required?

• Who issues the license?

• Who pays the license fee?

44. Does the worker have a financial investment in a business related to the services performed? Yes No Unknown

• If yes, specify and give amount of the investment.

45. Can the worker incur a loss in the performance of the service for the firm? Yes No

• If yes, how?

46. Has any other government agency ruled on the status of the firm’s workers? Yes No

• If yes, attach a copy of the ruling.

47. Is the same issue being considered by any IRS office in connection with the audit of the worker’s tax return or the firm’s tax return or has it been considered recently? Yes No

48. Does the worker assemble or process a product at home or away from the firm’s place of business? Yes No

• If yes, who furnishes materials or goods used by the worker?

• Is the worker furnished a pattern or given instruction to follow in making the product?

• Is the worker required to return the finished product to the firm or to someone designated by the firm?

49. Attach a detailed explanation of any other reason why you believe the worker is either an employee or an independent contractor.

50. Are leads to prospective customers furnished by the firm? Yes No

51. Is the worker required to pursue or report on leads? Yes No

52. Is the worker required to adhere to prices, terms, and conditions of sale established by the firm? Yes No

53. Are orders submitted to and subject to approval by the firm? Yes No

54. Is the worker expected to attend sales meetings? Yes No

• If yes, is the worker subject to any kind of penalty for failing to attend? Yes No

55. Does the firm assign a specific territory to the worker? Yes No

56. Whom does the customer pay? Firm Worker

57. Does the worker sell a consumer product in a home or establishment other than a permanent retail establishment? Yes No