ࡱ> Y bjbj[[ 4F9 \9 \ |$a8 XXXX3"Ui aaaaaaa$mc#f&au33uu&aXX;au^XXaua<[x_XX5gX4]8`Qa0al] f+Zfpx_fx_tuuuuuuu&a&aZuuuauuuufuuuuuuuuu > J:  Independent Contractor Status Determination and Documentation Form Section 1: Payment A. Name of individual or organization (MUST MATCH PSA AND W-9):______________________________________________________________________ B.  FORMCHECKBOX  YES  FORMCHECKBOX  NO Limited Liability Company (LLC). MUST select the federal entity type (Individual, Partnership, S-Corporation, or Corporation) C. Entity Type:  FORMCHECKBOX  Individual and or Sole Proprietor  FORMCHECKBOX  Partnership  FORMCHECKBOX  S-Corporation  FORMCHECKBOX  Corporation  FORMCHECKBOX  Government  FORMCHECKBOX  Tax-exempt Organization  FORMCHECKBOX  Private Foundation  FORMCHECKBOX  Disregarded Entity  FORMCHECKBOX  Simple Trust  FORMCHECKBOX  Grantor Trust  FORMCHECKBOX  Complex Trust  FORMCHECKBOX  Estate Central Bank of Issue  FORMCHECKBOX  International D. If payment will be made to an Individual, Sole Proprietor, a Partnership, or a Disregarded Entity complete section 2. If not, please sign and date. Section 2: Individual Current Relationship with SWAGƵ Name of Individual or Business Owner ______________________________________________________________________ Is this Individual / Business Owner related to a current SWAGƵ employee?  FORMCHECKBOX  YES  FORMCHECKBOX  NO II ( a). If Yes, to whom? ____________________________ What relationship? _________________________________ Other  FORMCHECKBOX  YES  FORMCHECKBOX  NO A. Is this individual currently an employee with SWAGƵ?  FORMCHECKBOX  YES  FORMCHECKBOX  NO B. Has this individual been an employee of SWAGƵ within the past 12 months?  FORMCHECKBOX  YES  FORMCHECKBOX  NO C. Does the department plan on hiring this individual as an employee within the next 12 months?  FORMCHECKBOX  YES  FORMCHECKBOX  NO D. Is this individual a state retiree or member of PERS? If the answer is No to all questions, proceed to questions in Section 3. If the answer is Yes to A, B, or C above, the individual must be classified as an employee and paid through SWAGƵ payroll. Complete a Personnel Action Form. If the answer is Yes to D above, Independent Contractor status must be approved by PERS. Section 3: Classification Guidelines (Complete only one section, A, B, or C, depending on the services to be performed by the individual.) A. Lecturer/Instructor  FORMCHECKBOX  YES  FORMCHECKBOX  NO 1. Is the individual a guest lecturer, e.g., an individual who lectures at only one or two class sessions?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 2. Is the individual the primary instructor in a department course being offered for academic credit toward a University degree?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 3. Is the individual responsible for the content of the lecture/presentation versus presenting materials that have been prepared/dictated by SWAGƵ? B. Researcher NOTE - Researchers hired to perform services for a University department are initially presumed to be employees of the University. Please complete the following questions:  FORMCHECKBOX  YES  FORMCHECKBOX  NO 1. Will the individual perform research for a University faculty member or director under an arrangement whereby the University faculty member or director serves in a supervisory capacity (i.e., the individual will be working under the direction of the University faculty member or director)?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 2. Will the individual serve in an advisory or consulting capacity with a University faculty member or director, in a collaboration between equals type arrangement? C. Individuals Not Covered Under Section 3A or 3B.  FORMCHECKBOX  YES  FORMCHECKBOX  NO 1. Does the individual routinely provide the same or similar services outside SWAGƵ to the general public as part of a continuing trade or business?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 2. Aside from a general request to work during SWAGƵ hours, will the University set the number of hours and/or days of the week that the individual is required to work, as opposed to allowing the individual to set own work schedule and/or pay the individual an hourly rate similar to what other employees are paid on campus for similar work?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 3. Aside from requesting what type of work needs to be done, will the department provide the individual with specific instructions how to perform the work rather than rely on the individuals expertise and/or provide significant supplies and equipment for the worker?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 4. Does the individual engage in entrepreneurial activities in an established business at risk for loss?  FORMCHECKBOX  YES  FORMCHECKBOX  NO 5. Does the individual have his/her own insurance for work-related injuries? 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