Form SS-8, Determination of Worker Status Instructions

Provide any additional information relevant to the worker's status.

Provide any other relevant details about the worker or the firm.

Provide any other relevant details about the worker or the firm.

Provide any other relevant details about the worker or the firm.

Provide an explanation as required by the form. This field is likely asking for additional details or context.

Provide additional information or details as required.

Provide additional information or details as required.

If you answered 'Yes' to any of the previous questions, provide an explanation here.

Provide any additional explanations or details related to the worker's status.

Provide additional details as requested in the form.

Provide additional details as requested in the form.

Provide additional information or details as requested in the form.

Provide additional information or details as requested in the form.

Check this box if the worker assembles or processes a product at home.

Check this box if the worker does not assemble or process a product at home.

Enter who provides the materials and instructions or patterns used for the worker’s home assembly or processing (for example: Firm, Worker, or name/description if Other). Fill only if 'Part IV, 7 - Does the worker assemble or process a product at home? (Yes)' is 'Yes'.

Check this box if, when the worker assembles/processes at home, they return the finished product to the firm. Fill only if 'Part IV, 7 - Does the worker assemble or process a product at home? (Yes)' is 'Yes'.

Check this box if the worker provides the finished product to another party (other than the firm). Fill only if 'Part IV, 7 - Does the worker assemble or process a product at home? (Yes)' is 'Yes'.

Check this box if the worker sells the finished product themselves. Fill only if 'Part IV, 7 - Does the worker assemble or process a product at home? (Yes)' is 'Yes'.

Check this box if the worker's handling of the finished product is not listed above and use the provided space to specify what they do. Fill only if 'Part IV, 7 - Does the worker assemble or process a product at home? (Yes)' is 'Yes'.

If the finished product disposition is not one of the listed options, describe what the worker does with the finished product (e.g., specific other disposition or recipient). Fill only if 'Part IV, 7 - Does the worker assemble or process a product at home? (Yes)', 'Part IV, 7 - Finished product disposition: Other (specify)' is 'Yes' all fields selection.

Check this box if the condition specified in the form applies to you.

Check this box if the condition specified in the form applies to you.

Check this box if the condition specified in the form applies to you.

Check this box if the condition specified in the form applies to you.

Check this box if the condition specified in the form applies to you.

Check this box if the answer to the corresponding question is 'No'.

Check this box if the answer to the corresponding question is 'Yes'.

Check this box if the answer to the corresponding question is 'No'.

Specify who assigns work to the worker.

Check this box if the answer to the corresponding question is 'Yes'.

Check this box if the worker is required to comply with instructions about when, where, and how the work is to be done.

Check this box if the worker is trained by the firm to perform services in a particular manner.

Check this box if the worker's services are integrated into the business operations of the firm.

Check this box if the worker is required to perform the work personally.

Provide details about who determines the methods by which the assignments are performed.

Specify who determines the methods by which the assignments are performed.

Specify who is contacted if problems or complaints arise.

Provide additional details relevant to the working relationship.

Provide an explanation if you answered 'Yes' to the previous question.

If the answer to the previous question is 'Yes', provide an explanation here.

Check this box if the employer/firm makes benefits available to the worker.

Check this box if the employer/firm does not make any benefits available to the worker.

Check this box if the worker is provided paid vacation time. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker receives sick pay or paid sick leave. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker receives paid holidays. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker is given paid personal days. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker is eligible for a pension or retirement plan. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker is offered insurance benefits (for example, health or dental insurance). Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker is eligible to receive bonuses. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Check this box if the worker receives some other benefit not listed here, and specify the benefit in the adjacent space. Fill only if '1. Are benefits made available to the worker? — Yes' is 'Yes'.

Enter any other benefit(s) made available to the worker that are not listed (for example, transportation allowance, tuition reimbursement, or flexible spending), written as a short descriptive phrase. Fill only if '1. Are benefits made available to the worker? — Yes', '1. Other (specify)' is 'Yes' all fields selection.

Describe any changes mentioned in the previous questions.

Check this box if the firm or the worker can end the work relationship without incurring any penalty.

Check this box if the firm or the worker cannot end the work relationship without incurring a penalty (if “No,” provide an explanation in the space provided).

If the answer to Part IV, question 2 is "No," describe in detail why the firm or worker cannot end the work relationship without penalty, giving specific circumstances, terms, or examples that explain the restriction. Fill only if 'Part IV, 2 — End Work Relationship Without Penalty: No' is 'Yes'.

If you answered 'Yes' to the previous question, describe the terms of the lease here. Attach a copy or an explanatory statement if necessary.

Provide the frequency and amount if you answered 'Yes' to the previous question.

If the answer to the previous question is 'Yes,' provide an explanation here.

If you answered 'Yes' to the previous question, specify the reporting requirements here.

If you answered 'Yes' to the previous question, provide an explanation here.

Check this box if the worker can suffer a financial loss as a result of performing the services (if checked, provide the explanation requested on the form).

Check this box if the worker cannot suffer a financial loss as a result of performing the services.

Describe briefly how the worker can suffer a financial loss by performing services, providing specific examples or circumstances (e.g., expenses, unreimbursed costs, liability) that explain the risk of loss. Fill only if 'Can the worker suffer a financial loss by performing services? — Yes' is 'Yes'.

Check this box if the worker takes a financial risk by performing the services (for example, the worker can incur a financial loss or have an opportunity for financial gain based on how the services are performed).

Check this box if the worker does not take a financial risk by performing the services (i.e., the worker cannot suffer a financial loss or gain based on how the services are performed).

Provide a brief explanation describing how and why the worker takes financial risk by performing services, including specific examples or circumstances that show the financial exposure. Fill only if 'Part III, 9a — Yes (Worker takes a financial risk)' is 'Yes'.

Enter the name of the firm or person for whom the worker performed services.

Provide the mailing address of the firm, including street address, apartment or suite number, city, state, and ZIP code.

Enter the trade name of the firm, if applicable.

Provide the fax number of the firm.

Enter the website URL of the firm.

Provide the telephone number of the firm, including the area code.

Enter the employer identification number (EIN) of the firm. This should be a 10-digit number.

Enter the name of the firm or company.

Enter the address of the firm or company.

Describe the nature of the firm's business.

Provide any other relevant details about the firm.

Provide any other relevant details about the firm.

Enter the name of the firm's previous owner.

Enter the taxpayer identification number of the firm's previous owner. This should be a number up to 11 digits long.

Check this box if the firm does introduce the worker to its customers.

Check this box if the firm does not introduce the worker to its customers.

Check this box if, when the firm introduces the worker to customers, the worker is introduced as an employee (only applicable if 'Yes' is checked). Fill only if '8a - Yes (Firm introduces the worker to its customers)' is 'Yes'.

Check this box if, when the firm introduces the worker to customers, the worker is introduced as a partner (only applicable if 'Yes' is checked). Fill only if '8a - Yes (Firm introduces the worker to its customers)' is 'Yes'.

Check this box if, when the firm introduces the worker to customers, the worker is introduced as a representative (only applicable if 'Yes' is checked). Fill only if '8a - Yes (Firm introduces the worker to its customers)' is 'Yes'.

Check this box if, when the firm introduces the worker to customers, the worker is introduced as a contractor (only applicable if 'Yes' is checked). Fill only if '8a - Yes (Firm introduces the worker to its customers)' is 'Yes'.

Check this box if the worker is introduced to customers in some other way and provide the method in the adjacent 'specify' space (only applicable if 'Yes' is checked). Fill only if '8a - Yes (Firm introduces the worker to its customers)' is 'Yes'.

If the firm introduces the worker to customers using a method not listed (Employee, Partner, Representative, Contractor), enter a brief description of that method here. Fill only if '8a - Yes (Firm introduces the worker to its customers)', '8a - Other (specify)' is 'Yes' all fields selection.

Check this box when the firm (not the worker) determines and sets the terms and conditions under which sales are made.

Check this box when the firm does not set the terms and conditions of sale (i.e., the worker or another party sets them).

If the firm sets terms and conditions of sale, provide a clear explanation of those terms and conditions that apply to the worker’s sales (for example: pricing rules, return/refund policy, required approvals, delivery or payment terms). Fill only if 'Part V, 4: Firm sets terms and conditions of sale — Yes' is 'Yes'.

Check this box if applicable to the specific question on Page 2, Section 2.

Check this box if applicable to the specific question on Page 2, Section 3.

Check this box if applicable to the specific question on Page 2, Section 3.

Check this box if applicable to the specific question on Page 2, Section 3.

Check this box if applicable to the specific question on Page 2, Section 3.

Check this box if applicable to the specific question on Page 2, Section 3.

Provide additional information as required in the specific question on Page 2, Section 3.

Provide additional information as required in the specific question on Page 2, Section 3.

Provide additional information as required in the specific question on Page 2, Section 3. This should be a text up to 8 characters long.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Please provide the relevant information for this field. The exact nature of the information required is not specified by the field name.

Provide the relevant information as requested in this text field.

Provide the relevant information as requested in this text field.

Provide the relevant information as requested in this text field.

Inform us of any current or past litigation concerning the worker's status.

Check this box if there is an agreement that prohibits competition between the firm and the worker.

Check this box if there is no agreement that prohibits competition between the firm and the worker.

Provide a clear explanation of any agreement that prohibits competition between the firm and the worker, including key terms such as whether a noncompete exists, its duration, geographic scope, specific restrictions, parties involved, and reference to or attachment of any supporting documentation. Fill only if 'Part IV, 4 - Noncompete agreement: Yes' is 'Yes'.

Check this box if the worker’s orders are submitted to the firm and those orders are subject to the firm’s approval.

Check this box if the worker’s orders are not submitted to the firm or the orders are not subject to the firm’s approval.

Enter a list or brief description of the supplies, equipment, materials, or property that the firm provides for the worker to perform the job.

Enter a list or brief description of the supplies, equipment, materials, or property that the worker provides for performing the services.

Check this box when supplies, equipment, materials, or other property used for the work are provided by a party other than the firm or the worker (i.e., another outside party).

Check this box when no supplies, equipment, materials, or property used for the work are provided by any party other than the firm or the worker.

Provide a detailed explanation of the supplies, equipment, materials, or property provided by another party, including what items were provided, the provider's name or relationship, quantities or values if known, and any conditions or terms associated with their provision. Fill only if 'Part III Q1b — Are supplies, equipment, materials, or property provided by another party? (Yes)' is 'Yes'.

Check this box if the worker leases any equipment, space, or a facility (in whole or in part) for performing the work described.

Check this box if the worker does not lease any equipment, space, or facility for performing the work.

Provide the full terms of the lease for the equipment, space, or facility, including lease start and end dates or duration, payment amount and frequency, who is responsible for maintenance and utilities, any restrictions or special conditions, and reference any attached lease copy or explanatory statement. Fill only if 'Part III Q2 — Leases equipment/space/facility: Yes' is 'Yes'.

Check this box if the worker does incur expenses while performing services for the firm.

Check this box if the worker does not incur any expenses while performing services for the firm.

Provide a clear explanation of expenses the worker incurred in performing services for the firm, including the type of expense, approximate amount, relevant dates or periods, and who paid or reimbursed each expense. Fill only if 'Part III Q3: Are expenses incurred by the worker in the performance of services for the firm? — Yes' is 'Yes'.

Check this box when the firm reimburses the worker for expenses incurred in performance of services; if checked, also provide the frequency and amount as requested.

Check this box when the firm does not reimburse the worker for expenses incurred in performance of services.

Enter how often the firm reimburses the worker and the reimbursement amount (for example, 'Monthly - $200', 'Per job - $50', or 'As incurred - variable'). Fill only if 'Part III Q4a: Are expenses reimbursed by the firm? — Yes' is 'Yes'.

Check this box if expenses incurred by the worker are reimbursed by a party other than the firm (answering 'Yes' to Part III, Question 4b).

Check this box if expenses incurred by the worker are not reimbursed by any party other than the firm (answering 'No' to Part III, Question 4b).

Enter the first line of your explanation about expenses reimbursed by another party, including who reimburses them and brief details such as the relationship to the worker, what expenses are covered, and any relevant amounts or frequency. Fill only if 'Part III Q4b - Yes (Are expenses reimbursed by another party?)' is 'Yes'.

Enter a continuation of the explanation for expenses reimbursed by another party, providing any additional details, amounts, terms, or examples needed to fully describe who reimburses the worker and how reimbursement is handled. Fill only if 'Part III Q4b - Yes (Are expenses reimbursed by another party?)' is 'Yes'.

Check this box if the worker is paid a regular salary (fixed periodic pay).

Check this box if the worker is paid primarily by commission (payment based on sales or performance).

Check this box if the worker is paid an hourly wage for time worked.

Check this box if the worker is paid by piece work (payment per unit produced or task completed).

Check this box if the worker is paid a lump-sum amount rather than periodic wages or hourly pay.

Check this box if the worker's type of pay is not listed above and provide the specific pay type in the space provided.

Enter the name or brief description of the other type of pay the worker receives if it is not one of the listed options (for example: tips, stipend, bonuses). Fill only if 'Part III Q5a Other (specify)' is 'Yes'.

Check this box if the worker is paid by commission and the firm guarantees a minimum amount of pay. Fill only if 'Part III Q5a Commission' is 'Yes'.

Check this box if the worker is paid by commission and the firm does not guarantee any minimum amount of pay. Fill only if 'Part III Q5a Commission' is 'Yes'.

If the worker is paid commission and the firm guarantees a minimum pay, describe that guarantee clearly — include the guaranteed amount (or how it is calculated), how often it is paid (e.g., weekly, monthly), any conditions or limits, and any other relevant terms. Fill only if 'Part III Q5a Commission', 'Part III Q5b — Commission minimum guarantee: Yes' are 'Yes' (all).

Check this box when the worker is allowed to request advance pay.

Check this box when the worker is not allowed to request advance pay.

Check this box when advance pay, if allowed, may be requested on a daily basis. Fill only if 'Part III Q6 — Can the worker request advance pay? Yes' is 'Yes'.

Check this box when advance pay, if allowed, may be requested on a weekly basis. Fill only if 'Part III Q6 — Can the worker request advance pay? Yes' is 'Yes'.

Check this box when advance pay, if allowed, may be requested on a monthly basis. Fill only if 'Part III Q6 — Can the worker request advance pay? Yes' is 'Yes'.

Check this box when advance pay, if allowed, may be requested at a different frequency and specify the frequency in the provided space. Fill only if 'Part III Q6 — Can the worker request advance pay? Yes' is 'Yes'.

If the worker can request advance pay and the frequency is not one of the listed options, type the specific frequency or interval here (for example, "biweekly", "per job", "every 2 weeks", or other descriptive timing). Fill only if 'Part III Q6 — Can the worker request advance pay? Yes', 'Part III Q6 — Advance pay frequency: Other (specify)' are 'Yes' (all).

Check this box if the customer pays the firm directly for the worker’s services.

Check this box if the customer pays the worker directly for the worker’s services.

Check this box if, when the worker is paid by the customer, the worker remits the total payment to the firm. Fill only if 'Q7 — Customer pays: Worker' is 'Yes'.

Check this box if, when the worker is paid by the customer, the worker does not remit the total payment to the firm (for example, retains or forwards only part of it). Fill only if 'Q7 — Customer pays: Worker' is 'Yes'.

Enter whether the worker pays the total amount received from the customer to the firm by typing 'Yes' or 'No'; if 'No' this field may be used for a brief note directing the reader to the full explanation. Fill only if 'Q7 — If worker paid, does worker remit total amount to firm: No' is 'Yes'.

If the worker does not remit the customer's full payment to the firm, provide a detailed explanation describing who the customer pays, how the funds are handled, and any remittance arrangements with the firm. Fill only if 'Q7 — If worker paid, does worker remit total amount to firm: No' is 'Yes'.

Check this box if the firm carries workers' compensation insurance that covers the worker.

Check this box if the firm does not carry workers' compensation insurance that covers the worker.

Check this box if the worker is provided leads (names and contact information) for potential new customers.

Check this box if the worker is not provided leads (names and contact information) for potential new customers.

Enter the name(s) and contact information of the person(s) or organization that provides leads or potential customer information for the worker. Fill only if 'Part V, 2 — Provided Leads: Yes' is 'Yes'.

Check this box if the worker is allowed to hire substitutes or helpers to perform the work.

Check this box if the worker is not allowed to hire substitutes or helpers to perform the work.

Check this box if the worker sells life insurance as their full-time occupation (i.e., they primarily sell life insurance).

Check this box if the worker does not sell life insurance full time (i.e., selling life insurance is not their primary occupation).

Check this box if the worker sells other types of insurance on behalf of the firm.

Check this box if the worker does not sell other types of insurance for the firm.

Enter the percentage of the worker’s total working time spent selling other types of insurance for the firm. Fill only if 'Q11 Yes - Sells other types of insurance for the firm' is 'Yes'.

Check this box if approval is required before the worker can hire substitutes or helpers.

Check this box if the worker may hire substitutes or helpers without prior approval.

Check this box if the firm (employer/business) is the party that approves hiring substitutes or helpers. Fill only if 'Q11 - Approval Required: Yes' is 'Yes'.

Check this box if an approver other than the firm is responsible for approving hires, and write that approver in the adjacent 'Other (specify)' field. Fill only if 'Q11 - Approval Required: Yes' is 'Yes'.

Enter the name or title of the person, firm, or other entity who approves the hiring of substitutes or helpers when 'Other (specify)' is selected. Fill only if 'Q11 - Approval Required: Yes', 'Q11 - Approver: Other (specify)' are 'Yes' (all).

Check this box if the worker solicits orders from wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar establishments.

Check this box if the worker does not solicit orders from wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar establishments.

Enter the percentage of the worker’s total working time that is spent soliciting orders from wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar establishments. Fill only if 'Q12 Solicits orders — Yes' is 'Yes'.

Check this box if the worker does pay substitutes or helpers.

Check this box if the worker does not pay substitutes or helpers.

Check this box if, when the worker pays substitutes or helpers, the worker is reimbursed. Fill only if 'Q12 - Worker pays substitutes or helpers: Yes' is 'Yes'.

Check this box if, when the worker pays substitutes or helpers, the worker is not reimbursed. Fill only if 'Q12 - Worker pays substitutes or helpers: Yes' is 'Yes'.

Enter the name(s) or description of the person, firm, or entity that reimburses the worker for substitutes or helpers (who pays the reimbursement). Fill only if 'Q12 - Worker reimbursed for substitutes/helpers: Yes' is 'Yes'.

Check this box if the merchandise is purchased by the customers for resale or for use in their business operations.

Check this box if the merchandise is not purchased by the customers for resale or for use in their business operations.

Describe the merchandise customers purchase (for resale or use in their business) and state whether the item is equipment installed on the customers' premises. Fill only if 'Q13 Yes — Merchandise purchased by customers' is 'Yes'.

Check this box when the worker is required to complete reports (attach examples when applicable).

Check this box when the worker is not required to complete reports.

Check this box if the worker performs services on a regular, prearranged schedule (specific days/times).

Check this box if the worker performs services only when required or in response to specific needs or requests.

Check this box if the worker performs services when they are available but without a fixed schedule.

Check this box if the frequency does not match the listed options and write the specific frequency in the space provided.

Enter the specific frequency or scheduling details when the worker’s service frequency is not covered by the provided options (e.g., "Twice weekly," "First and third Mondays," "Seasonal/quarterly"). Fill only if 'Q6a Other (specify)' is 'Yes'.

Check this box when the worker's primary service involves sales activities.

Check this box when the worker's primary service involves preparing, managing, or completing timesheets.

Check this box when the worker's primary service involves maintaining patient logs or patient record entries.

Check this box when the worker's primary service is not listed above, and specify the service on the provided line.

Enter a brief description of the worker’s primary services performed; if you selected “Other (specify)” on the form, provide the specific service(s) here. Fill only if 'Other (specify)' is 'Yes'.

Check this box if the worker did pay for the privilege of serving customers on the route or in the territory.

Check this box if the worker did not pay for the privilege of serving customers on the route or in the territory.

Enter the name of the person or business to whom the worker paid for the privilege of serving customers on the route or in the territory. Fill only if 'Q7 Yes' is 'Yes'.

Enter the total amount the worker paid for the privilege of serving customers on the route or in the territory. Fill only if 'Q7 Yes' is 'Yes'.

Check this box if the worker performs services at the firm's premises, then enter the percentage of time spent there.

Percentage of the worker's total work time spent at the employer's firm premises. Fill only if 'Firm premises' is 'Yes'.

Check this box if the worker performs services at their own office or shop, then enter the percentage of time spent there.

Percentage of the worker's total work time spent at the worker's own office or shop. Fill only if 'Worker's office or shop' is 'Yes'.

Check this box if the worker travels to and performs services at a customer's location, then enter the percentage of time spent there.

Percentage of the worker's total work time spent at customers' locations. Fill only if 'Customer's location' is 'Yes'.

Check this box if the services are performed at a different location not listed, then specify that location and enter the percentage of time spent there.

Enter a brief description or name of any other location where the worker performs services. Fill only if 'Other (specify)' is 'Yes'.

Percentage of the worker's total work time spent at the specified other location. Fill only if 'Other (specify)' is 'Yes'.

Check this box if the worker sells the product at a home or other residential location.

Check this box if the worker sells the product at a retail store or other commercial establishment.

Check this box if the worker sells the product online (via the internet).

Check this box if the worker sells the product in a location not listed above and specify that location on the provided line.

Enter the specific 'Other' location where the worker sells the product (for example: at fairs, customer's homes, kiosks, market stalls, etc.). Fill only if 'Other (specify)' is 'Yes'.

Check this box if the worker is required to attend meetings.

Check this box if the worker is not required to attend meetings.

Check this box if the meetings the worker is required to attend are sales meetings (use only if 'Yes' is checked). Fill only if 'Yes' is 'Yes'.

Check this box if the meetings the worker is required to attend are staff meetings (use only if 'Yes' is checked). Fill only if 'Yes' is 'Yes'.

Check this box if the meetings are some other type and provide the meeting type in the accompanying 'Other (specify)' field (use only if 'Yes' is checked). Fill only if 'Yes' is 'Yes'.

Enter the type of meeting(s) the worker is required to attend; if 'Other,' specify the meeting type or details here. Fill only if 'Yes', 'Other (specify)' are 'Yes' (all).

Check this box when the worker is penalized for being unable to attend a required meeting.

Check this box when the worker is not penalized for being unable to attend a required meeting.

Enter the specific penalty imposed if the worker is penalized for failing to attend a meeting (for example, an amount withheld, loss of hours/pay, suspension, or a brief description of the disciplinary action). Fill only if 'Is the worker penalized if unable to attend a meeting? — Yes' is 'Yes'.

Enter the principal product or service the worker distributes (a short label or name of the main product/service).

Provide a more detailed description or examples of the product(s) and/or service(s) distributed by the worker (e.g., types, categories, or clarifying details).

Check this box if the worker must personally perform the services (i.e., the services cannot be performed by substitutes or helpers).

Check this box if the worker is not required to personally perform the services (i.e., substitutes or helpers may perform the work).

Check this box if the worker is required to report on potential new customers they contact.

Check this box if the worker is not required to report on potential new customers they contact.

Provide the detailed reporting requirements the worker must follow when reporting potential new customers, including what information must be reported, how often or within what timeframe, and to whom or where the reports must be submitted. Fill only if 'Part V, 3 — Is the worker required to report on potential new customers contacted? (Yes)' is 'Yes'.

Check this box when the worker is responsible for contacting potential new customers (i.e., they actively reach out to or solicit new clients).

Check this box when the worker is not responsible for contacting potential new customers.

If the worker is responsible for contacting potential new customers, describe the worker’s specific duties and actions taken to contact or solicit new customers (for example: calling prospects, scheduling appointments, providing product information, following up on leads, or other sales activities). Fill only if 'Part V, 1 - Is the worker responsible for contacting potential new customers? — Yes' is 'Yes'.

Describe the merchandise and state whether it is equipment installed on the customers' premises.

If you answered 'Yes' to the previous question, provide the dates of service.

Enter the month and year when the services began (MM/YYYY).

Enter the month and year when the services ended (MM/YYYY).

Check this box if the worker did perform similar services for other clients during the time period entered in Part I, line 1.

Check this box if the worker did not perform similar services for other clients during the time period entered in Part I, line 1.

Check this box if, when the worker performed similar services for others, the worker was required to obtain approval from the firm. Fill only if 'Part IV, 3 — Performed similar services for others: Yes' is 'Yes'.

Check this box if, when the worker performed similar services for others, the worker was not required to obtain approval from the firm. Fill only if 'Part IV, 3 — Performed similar services for others: Yes' is 'Yes'.

Check this box if the worker currently still performs services for the firm.

Check this box if the worker no longer performs services for the firm.

Check this box if the working relationship ended because the firm terminated or ended it. Fill only if '9. Does the worker still perform services for the firm? — No' is 'Yes'.

Check this box if the working relationship ended because the worker voluntarily ended it. Fill only if '9. Does the worker still perform services for the firm? — No' is 'Yes'.

Check this box if the working relationship ended because the specific job or assignment was completed. Fill only if '9. Does the worker still perform services for the firm? — No' is 'Yes'.

Check this box if the working relationship ended due to the contract term expiring or the contract ending. Fill only if '9. Does the worker still perform services for the firm? — No' is 'Yes'.

Check this box if the relationship ended because either the firm or the worker went out of business. Fill only if '9. Does the worker still perform services for the firm? — No' is 'Yes'.

Check this box if the relationship ended for a reason not listed and provide the specific reason in the space provided. Fill only if '9. Does the worker still perform services for the firm? — No' is 'Yes'.

If the worker does not still perform services for the firm, provide a short description of how the work relationship ended (for example: job completed, contract ended, firm or worker went out of business, or a different reason). Fill only if '9. Does the worker still perform services for the firm? — No', '9. If 'No,' how did the work relationship end? — Other (specify)' is 'Yes' all fields selection.

This field appears to be unnamed. Please refer to the form for specific instructions on what information to provide here.

Check this box when the services were performed under the firm's name (i.e., the firm is listed as the party providing the services).

Check this box when the services were performed under the worker's own name (i.e., the worker is listed as the party providing the services).

Check this box when the services were performed under a name other than the firm or worker; also provide the specific name in the adjacent 'Other (specify)' text field or line.

Enter the full name or trade name under which the services were performed when 'Other' is selected (for example, a different business name, DBA, or individual name). Fill only if '8b - Other (specify)' is 'Yes'.

Check this box if the firm (employer/company) is the party that determines the worker's sales territory.

Check this box if the worker themself decides or controls their own sales territory.

Check this box if someone or some entity other than the firm or the worker determines the sales territory, and specify who in the provided space.

If the firm/worker/firm option does not apply, enter who determines the worker's sales territory (for example a specific person, title, department, or outside party) and any brief identifying details such as name or relationship. Fill only if 'Part V, 6 - Other (specify)' is 'Yes'.

Check this box if, when products are sold, the firm (not the worker) determines the product price.

Check this box if, when products are sold, the worker (not the firm) determines the product price.

Check this box if someone other than the firm or worker sets the product price, and provide the specifying information in the space provided.

If the checkbox 'Other (specify)' was selected for 10b, enter the person, role, or entity that sets the product price (name, title, or brief description); otherwise leave blank. Fill only if 'Part III, 10b - Other (specify)' is 'Yes'.

Check this box if the firm (employer) sets the rate of pay for the services performed.

Check this box if the worker personally sets the rate of pay for the services performed.

Check this box if someone other than the firm or worker sets the rate of pay, and provide the specific party in the space provided.

If the person who sets the rate of pay is not the Firm or Worker, enter the name, title, or brief description of the person or entity who sets the pay rate (for example, 'Operations Manager', 'Payroll Department', or the specific company/individual). Fill only if '10a - Other (specify)' is 'Yes'.

If the answer to the previous question is 'Yes', describe the terms and conditions of the work arrangement in detail.

Provide additional details about the work arrangement if necessary.

Provide further information about the work arrangement if needed.

Provide additional information related to the work arrangement.

Provide further details about the work arrangement if necessary.

Provide more information about the work arrangement if needed.

Provide additional details about the work arrangement if necessary.

Provide further information about the work arrangement if needed.

Check this box when the worker does advertise (for example, places ads, posts listings, or otherwise promotes their services or products).

Check this box when the worker does not advertise in any way to promote their services or products.

Enter the type(s) of advertising the worker uses (for example: flyers, brochures, newspaper or classified ads, online ads, social media, business cards), listing multiple methods separated by commas. Fill only if 'Part IV, 6 - Does the worker advertise? Yes' is 'Yes'.

Check this box if the worker is an employee.

Check this box if the worker is an independent contractor.

Check this box if the worker is classified as an employee.

Check this box if the worker is classified as an independent contractor.

Check this box if the worker is classified as a statutory employee.

Check this box if the worker is classified as a statutory nonemployee.

Provide additional details about the worker's classification.

Enter the full name of the worker.

Provide the mailing address of the worker, including street address, apartment or suite number, city, state, and ZIP code.

Enter the daytime telephone number of the worker.

Provide an alternate telephone number for the worker.

Enter the fax number of the worker.

Provide the social security number (SSN) of the worker. This should be an 11-digit number.

Enter the employer identification number (EIN) of the worker, if any. This should be a 10-digit number.

Enter the name of the worker whose status is being determined.

Enter the total number of workers who performed or are performing the same or similar services.

Enter the job title of the worker.

Describe the duties performed by the worker.

If the answer to the previous question is 'Yes,' specify the worker's specific responsibilities.

Provide additional details or comments related to the worker's responsibilities.

Check this box if the worker is a service provider.

Check this box if the worker is a salesperson.

Check this box if the worker is a consultant.

Check this box if the worker is a freelancer.

Check this box if the worker is a temporary worker.

Check this box if the worker is a service provider or salesperson.

Provide additional details about the worker's role or services provided.

Provide additional details about the worker's role or services provided.

Provide additional details about the relationship between the worker and the firm.

Provide additional details about the relationship between the worker and the firm.

Provide detailed information about the specific aspect of the working relationship being queried.

Provide additional details or explanations as required by the form.