Form SS-8 (Rev. 1-2001)

Name of firm (or person) for whom the worker performed services Worker’s name

Firm’s address (include street address, apt. or suite no., city, state, and ZIP code) Worker’s address (include street address, apt. or suite no., city, state,

and ZIP code)

Trade name Telephone number (include area code) Worker’s social security number

Telephone number (include area code) Firm’s employer identification number

This form is being completed by: Firm Worker; for services performed to . (beginning date) (ending date)

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

How did the worker obtain the job? Application Bid Employment Agency Other (specify)

Describe the firm’s business.

Describe the work done by the worker and provide the worker’s job title.

Did the worker perform services for the firm before getting this position?

If “Yes,” what were the dates of the prior service?

If “Yes,” explain the differences, if any, between the current and prior service.

If the work is done under a written agreement between the firm and the worker, attach a copy (preferably signed by both parties). Describe

the terms and conditions of the work arrangement.

A

Important Information Needed To Process Your Request

If this form is being completed by the worker, the IRS must have your permission to disclose your name to the firm. Do

you object to disclosing your name and the information on this form to the firm?

If you answered “Yes” or did not check a box, stop here. The IRS cannot act on your request and a determination will not be issued.

Yes No

C

D

You must answer ALL items OR mark them “Unknown” or “Does not apply.” If you need more space, attach another sheet.

Yes No N/A

F

G

I

J

Explain your reason(s) for filing this form (e.g., you received a bill from the IRS, you believe you received a Form 1099 or Form W-2 erroneously,

you are unable to get worker’s compensation benefits, you were audited or are being audited by the IRS).

B

Attach copies of all supporting documentation (contracts, invoices, memos, Forms W-2, Forms 1099, IRS closing agreements, IRS rulings, etc.).

In addition, please inform us of any current or past litigation concerning the worker’s status. If no income reporting forms (Form 1099-MISC or

W-2) were furnished to the worker, enter the amount of income earned for the year(s) at issue $ .

E

H Explain why you believe the worker is an employee or an independent contractor.

Worker’s employer identification number (if any)

( )

( )

Determination of Worker Status

for Purposes of Federal Employment Taxes

and Income Tax Withholding

Form SS-8

OMB No. 1545-0004 (Rev. January 2001)

Department of the Treasury

Internal Revenue Service

For Privacy Act and Paperwork Reduction Act Notice, see page 5. Cat. No. 16106T
Form SS-8 (Rev. 1-2001) Page 2

Form SS-8 (Rev. 1-2001)

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List the supplies, equipment, materials, and property provided by each party:

The firm

The worker

Other party

Does the worker lease equipment?

If “Yes,” what are the terms of the lease? (Attach a copy or explanatory statement.)

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

Specify which, if any, expenses are reimbursed by:

The firm

Other party

Type of pay the worker receives: Salary Commission Hourly Wage Piece Work

Lump Sum Other (specify)

If type of pay is commission, and the firm guarantees a minimum amount of pay, specify amount $ .

If the worker is paid by a firm other than the one listed on this form for these services, enter name, address, and employer identification

number of the payer.

Is the worker allowed a drawing account for advances?

If “Yes,” how often?

Specify any restrictions.

Whom does the customer pay? Firm Worker

If worker, does the worker pay the total amount to the firm?

Does the firm carry worker’s compensation insurance on the worker?

What economic loss or financial risk, if any, can the worker incur beyond the normal loss of salary (e.g., loss or damage of equipment,

material, etc.)?

Yes No

6

Part II Financial Control

Yes No

If “No,” explain.

Yes No

Yes No

1 What specific training and/or instruction is the worker given by the firm?

2 How does the worker receive work assignments?

3 Who determines the methods by which the assignments are performed?

4 Who is the worker required to contact if problems or complaints arise and who is responsible for their resolution?

5 What types of reports are required from the worker? Attach examples.

Describe the worker’s daily routine (i.e., schedule, hours, etc.).

7 At what location(s) does the worker perform services (e.g., firm’s premises, own shop or office, home, customer’s location, etc.)?

8 Describe any meetings the worker is required to attend and any penalties for not attending (e.g., sales meetings, monthly meetings, staff

meetings, etc.).

9 Is the worker required to provide the services personally?

10 If substitutes or helpers are needed, who hires them?

11 If the worker hires the substitutes or helpers, is approval required?

If “Yes,” by whom?

12 Who pays the substitutes or helpers?

13 Is the worker reimbursed if the worker pays the substitutes or helpers?

If “Yes,” by whom?

Part I Behavioral Control

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Yes No

Yes No

Yes No
Form SS-8 (Rev. 1-2001) Page 3

Form SS-8 (Rev. 1-2001)

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For Service Providers or Salespersons—Complete this part if the worker provided a service directly to

customers or is a salesperson.

What are the worker’s responsibilities in soliciting new customers?

Who provides the worker with leads to prospective customers?

Describe any reporting requirements pertaining to the leads.

What terms and conditions of sale, if any, are required by the firm?

Are orders submitted to and subject to approval by the firm?

Who determines the worker’s territory?

Did the worker pay for the privilege of serving customers on the route or in the territory?

If “Yes,” whom did the worker pay?

If “Yes,” how much did the worker pay?

Where does the worker sell the product (e.g., in a home, retail establishment, etc.)?

List the product and/or services distributed by the worker (e.g., meat, vegetables, fruit, bakery products, beverages, or laundry or dry cleaning

services). If more than one type of product and/or service is distributed, specify the principal one.

Does the worker sell life insurance full time?

Does the worker sell other types of insurance for the firm?

If “Yes,” enter the percentage of the worker’s total working time spent in selling other types of insurance. %

If the worker solicits orders from wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar

establishments, enter the percentage of the worker’s time spent in the solicitation. %

Is the merchandise purchased by the customers for resale or use in their business operations?

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

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  Title  Date 

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Part IV

Yes No

Yes No

Yes No

Yes No

Yes No

$

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(Type or print name below)

Part V Signature (see page 4)

List the benefits available to the worker (e.g., paid vacations, sick pay, pensions, bonuses).

Can the relationship be terminated by either party without incurring liability or penalty?

If “No,” explain your answer.

Does the worker perform similar services for others?

If “Yes,” is the worker required to get approval from the firm?

Is the worker a member of a union?

What type of advertising, if any, does the worker do (e.g., a business listing in a directory, business cards, etc.)? Provide copies, if applicable.

If the worker assembles or processes a product at home, who provides the materials and instructions or pattern?

What does the worker do with the finished product (e.g., return it to the firm, provide it to another party, or sell it)?

How does the firm represent the worker to its customers (e.g., employee, partner, representative, or contractor)?

Describe any agreements prohibiting competition between the worker and the firm while the worker is performing services or during any later

period. Attach any available documentation.

If the worker no longer performs services for the firm, how did the relationship end?

Part III

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Yes No

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Relationship of the Worker and Firm

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Purpose

Firms and workers file Form SS-8 to request a determination

of the status of a worker for purposes of Federal

employment taxes and income tax withholding.

A Form SS-8 determination may be requested only in

order to resolve Federal tax matters. The taxpayer requesting

a determination must file an income tax return for the years

under consideration before a determination can be issued. If

Form SS-8 is submitted for a tax year for which the statute

of limitations on the tax return has expired, a determination

letter will not be issued. The statute of limitations expires 3

years from the due date of the tax return or the date filed,

whichever is later.

Definition

Firm. For the purposes of this form, the term “firm” means

any individual, business enterprise, organization, state, or

other entity for which a worker has performed services. The

firm may or may not have paid the worker directly for these

services. If the firm was not responsible for payment for

services, please be sure to complete question 6 in Part II

of Form SS-8.

The SS-8 Determination Process

The IRS will acknowledge the receipt of your Form SS-8.

Because there are usually two (or more) parties who could be

affected by a determination of employment status, the IRS

attempts to get information from all parties involved by

sending those parties blank Forms SS-8 for completion. The

case will be assigned to a technician who will review the

facts, apply the law, and render a decision. The technician

may ask for additional information before rendering a

decision. The IRS will generally issue a formal determination

to the firm or payer (if that is a different entity), and will send

a copy to the worker. A determination letter applies only to a

worker (or a class of workers) requesting it, and the decision

is binding on the IRS. In certain cases, a formal

determination will not be issued; instead, an information

letter may be issued. Although an information letter is

advisory only and is not binding on the IRS, it may be used

to assist the worker to fulfill his or her Federal tax

obligations. This process takes approximately 120 days.

Signature

The Form SS-8 must be signed and dated by the taxpayer.

A stamped signature will not be accepted.

The person who signs for a corporation must be an officer

of the corporation who has personal knowledge of the facts.

If the corporation is a member of an affiliated group filing a

consolidated return, it must be signed by an officer of the

common parent of the group.

The person signing for a trust, partnership, or limited

liability company must be, respectively, a trustee, general

partner, or member-manager who has personal knowledge of

the facts.

Completing Form SS-8

Please answer all questions as completely as possible.

Attach additional sheets if you need more space. Provide

information for all years the worker provided services for the

firm. Determinations are based on the entire relationship

between the firm and the worker.

Instructions for Workers

If you are requesting a determination for more than one firm,

complete a separate Form SS-8 for each firm.

Form SS-8 is not a claim for refund of social security

and Medicare taxes or Federal income tax

withholding.

Fee

There is no fee for requesting an SS-8 determination letter.

Where To File

Send the completed Form SS-8 to the address listed below

for the firm’s location. However, for cases involving Federal

agencies, send the form to the Internal Revenue Service,

Attn: CC:CORP:T:C, Ben Franklin Station, P.O. Box 7604,

Washington, DC 20044.

Firm’s location: Send to:

Alaska, Arizona, Arkansas,

California, Colorado, Hawaii,

Idaho, Illinois, Iowa, Kansas,

Minnesota, Missouri, Montana,

Nebraska, Nevada, New

Mexico, North Dakota,

Oklahoma, Oregon, South

Dakota, Texas, Utah,

Washington, Wisconsin,

Wyoming, American Samoa,

Guam, Puerto Rico, U.S. Virgin

Islands

Internal Revenue Service

SS-8 Determinations

P.O. Box 1231

Stop 4106 AUCSC

Austin, TX 78767

Alabama, Connecticut,

Delaware, District of Columbia,

Florida, Georgia, Indiana,

Kentucky, Louisiana, Maine,

Maryland, Massachusetts,

Michigan, Mississippi, New

Hampshire, New Jersey, New

York, North Carolina, Ohio,

Pennsylvania, Rhode Island,

South Carolina, Tennessee,

Vermont, Virginia, West Virginia,

all other locations not listed

Internal Revenue Service

SS-8 Determinations

40 Lakemont Road

Newport, VT 05855-1555 Neither the SS-8 determination process nor the review of

any records in connection with the determination constitutes

an examination (audit) of any Federal tax return. If the

periods under consideration have previously been examined,

the SS-8 determination process will not constitute a

reexamination under IRS reopening procedures. Because this

is not an examination of any Federal tax return, the appeal

rights available in connection with an examination do not

apply to an SS-8 determination. However, if you disagree

with a determination and you have additional information

concerning the work relationship that you believe was not

previously considered, you may request that the determining

office reconsider the determination.

The IRS does not issue a determination letter for proposed

transactions or on hypothetical situations. We may, however,

issue an information letter when it is considered appropriate.

Additional copies of this form may be obtained by calling

1-800-TAX-FORM (1-800-829-3676) or from the IRS Web Site

at www.irs.gov.

Form SS-8 (Rev. 1-2001) Page 4

If you are found to be an employee, you are responsible

for filing an amended return for any corrections related to

this decision. A determination that a worker is an employee

does not necessarily reduce any current or prior tax liability.

For more information, call 1-800-829-1040.

General Instructions

Section references are to the Internal Revenue Code unless

otherwise noted.
Form SS-8 (Rev. 1-2001) Page 5

If you have a reasonable basis for not treating a worker as

an employee, you may be relieved from having to pay

employment taxes for that worker under section 530 of the

1978 Revenue Act. However, this relief provision cannot be

considered in conjunction with a Form SS-8 determination

because the determination does not constitute an

examination of any tax return. For more information regarding

section 530 of the 1978 Revenue Act and to determine if you

qualify for relief under this section, you may visit the IRS

Web Site at www.irs.gov.

Instructions for Firms

If a worker has requested a determination of his or her

status while working for you, you will receive a request from

the IRS to complete a Form SS-8. In cases of this type, the

IRS usually gives each party an opportunity to present a

statement of the facts because any decision will affect the

employment tax status of the parties. Failure to respond to

this request will not prevent the IRS from issuing an

information letter to the worker based on the information he

or she has made available so that the worker may fulfill his

or her Federal tax obligations. However, the information that

you provide is extremely valuable in determining the status of

the worker.

If you are requesting a determination for a particular class

of worker, complete the form for one individual who is

representative of the class of workers whose status is in

question. If you want a written determination for more than

one class of workers, complete a separate Form SS-8 for

one worker from each class whose status is typical of that

class. A written determination for any worker will apply to

other workers of the same class if the facts are not materially

different for these workers. Please provide a list of names

and addresses of all workers potentially affected by this

determination.

Filing Form SS-8 does not alter the requirement to timely

file an income tax return. Do not delay filing your tax return

in anticipation of an answer to your SS-8 request. You must

file an income tax return for related tax years before a

determination can be issued. In addition, if applicable, do not

delay in responding to a request for payment while waiting

for a determination of your worker status.

Form SS-8 does not prevent the expiration of the time in

which a claim for a refund must be filed. If you are

concerned about a refund, and the statute of limitations for

filing a claim for refund for the year(s) at issue has not yet

expired, you should file Form 1040X, Amended U.S.

Individual Income Tax Return, to protect your statute of

limitations. File a separate Form 1040X for each year.

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated

average time is: Recordkeeping, 22 hrs.; Learning about

the law or the form, 47 min.; and Preparing and sending

the form to the IRS, 1 hr., 11 min. If you have comments

concerning the accuracy of these time estimates or

suggestions for making this form simpler, we would be happy

to hear from you. You can write to the Tax Forms Committee,

Western Area Distribution Center, Rancho Cordova, CA

95743-0001. Do not send the tax form to this address.

Instead, see Where To File on page 4.

You are not required to provide the information requested

on a form that is subject to the Paperwork Reduction Act

unless the form displays a valid OMB control number. Books

or records relating to a form or its instructions must be

retained as long as their contents may become material in

the administration of any Internal Revenue law. Generally, tax

returns and return information are confidential, as required by

section 6103.

Privacy Act and Paperwork Reduction Act Notice. We ask

for the information on this form to carry out the Internal

Revenue laws of the United States. This information will be

used to determine the employment status of the worker(s)

described on the form. Subtitle C, Employment Taxes, of the

Internal Revenue Code imposes employment taxes on

wages. Sections 3121(d), 3306(a), and 3401(c) and (d) and

the related regulations define employee and employer for

purposes of employment taxes imposed under Subtitle C.

Section 6001 authorizes the IRS to request information

needed to determine if a worker(s) or firm is subject to these

taxes. Section 6109 requires you to provide your taxpayer

identification number. Neither workers nor firms are required

to request a status determination, but if you choose to do

so, you must provide the information requested on this form.

Failure to provide the requested information may prevent us

from making a status determination. If any worker or the firm

has requested a status determination, and you are being

asked to provide information for use in that determination,

you are not required to provide the requested information.

However, failure to provide such information will prevent the

IRS from considering it in making the status determination.

Providing false or fraudulent information may subject you to

penalties. Routine uses of this information include providing

it to the Department of Justice for use in civil and criminal

litigation, to the Social Security Administration for the

administration of social security programs, and to cities,

states, and the District of Columbia for the administration of

their tax laws. We may also provide this information to the

affected worker(s) or the firm as part of the status

determination process.

Time for filing a claim for refund. Generally, you must file

your claim for a credit or refund within 3 years from the date

your original return was filed or within 2 years from the date

the tax was paid, whichever is later.

On the Form 1040X you file, do not complete lines 1

through 24 on the form. Write “Protective Claim” at the top

of the form, sign and date it. In addition, you should enter

the following statement in Part II, Explanation of Changes to

Income, Deductions, and Credits: “Filed Form SS-8 with the

Internal Revenue Service Office in (Austin, TX; Newport, VT;

or Washington, DC; as appropriate). By filing this protective

claim, I reserve the right to file a claim for any refund that

may be due after a determination of my employment tax

status has been completed.”