Form $S-8 (Rev. 1-88) Page 4

Answer items 18a through n if the worker is a salesman or provides a service directly to customers.

18a Are leads to prospective customers furnished by thefirm?. . . ....... .. .. Yes C1 No CO Doesnot apply
b Is the worker required to pursue or reportonleads? . . . . . . .O) Yes (] No [J Doesnot apply
c_ ts the worker required to adhere to prices, terms, and conditions of sale established by the firm? oe . OYes (No
d Are orders submitted to and subject to approvalbythefirm?.. ..................,... O¥es (No
e |s the worker expected to attend sales meetings? . . . . we ee eee ee ee es. Yes DINO
If yes: Is the worker subject to any kind of penalty for failing to attend? coe wee ee ee ss . Yes No
f Does the firm assign a specific territory tothe worker? . . . . . . ....... . .0) Yes 11 No C Doesnot apply
g Who does the customer pay? C Firm [1 Worker
If worker, does the worker remit the total amount tothe firm?. . . . . OYes CINo

m_ Does the worker sell life insurance?

19

20

h_ Does the worker sell a consumer product in a home or establishment other than a 3 permanent retail establishment? . OYes O1No
List the products and/or services distributed by the worker, such as meat, vegetables, fruit, bakery products,
beverages (other than milk), or laundry or dry cleaning services. If more than one type of product and/or service is
distributed, specify the principal one.
j Were the route or territory and a list of customers assigned to the worker by the firm or another person? . . . . . ClYes [INo
If yes, please identify the person who made the assignment.
k Did the worker pay the firm or person for the privilege of serving customers on the route or in the ‘territory? .... (Yes O1No
If yes, how much did the worker pay (not including any amount paid for a truck or racks, etc.)? $_
What factors were considered in determining the value of the route or territory?
How are new customers obtained by the worker? Explain fully, showing whether the new customers called the firm
for service, were solicited by the worker, or both..

If yes:
Is the selling of life insurance or annuity contracts for the firm the worker’s entire business activity? . . . . . C1 Yes ONo
If no, state the extent of the worker’s other business activities
Does the worker sell other types of insurance for the firm? :
If yes, state the percentage of the worker's total working time spenti in selling such other types of i insurance .................../ %
State if, at the time the contract was entered into between the firm and the worker, their intention was that the
worker would be considered as selling life insurance for the firm (a) on a full-time basis, or (b) on a part-time
basis. State the manner in which such intention was expressed.
n_ Is the worker a traveling salesperson or city salesperson?
If yes:
Specify from whom the worker principally solicits orders on behalf of the firm.
If the worker solicits orders from whole alers, retailers, contractors, or operators of hotels, restaurants, or other similar
establishments, specify the percentage of the worker's time spent in such solicitation. ......... %
ls the merchandise purchased by the customers for resale, or is it purchased for use in their business operations? If used by the
customers in their business operations, describe the merchandise and state whether it is equipment that is installed on their
premises or is a consumable supply.
Attach the names and addresses of the total number of workers in this class from page 1, or the names and addresses of 10 such
workers if there are more than 10.
Attach a detailed explanation for any other reason why you believe the worker is an independent contractor or is an employee of the firm.

IMPORTANT INFORMATION NEEDED TO PROCESS YOUR REQUEST
Under section 6110 of the Internal Revenue Code, the text and related background file documents of any ruling, determination letter,
or technical advice memorandum will be open to public inspection. This section provides that before the text and background file
documents are made public, identifying and certain other information must be deleted.
Are the names, addresses, and taxpayer identifying numbers the only items you wantdeleted? .. . . .... O1Yes ONo
If you checked No and believe additional deletions should be made, we cannot process your request unless you submit a copy of this
form and copies of all supporting documents indicating, in brackets, those parts you believe should be deleted in accordance with
section 6110(c) of the Code. Attach a separate statement indicating which specific exemption provided by section 6110(c) applies to
each bracketed part.

Under penalties of perjury, | declare that | 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 >

If this form is used by the firm in requesting a written determination, the form should be signed by an officer or member of the firm.
If this form is used by the worker in requesting a written determination, the form should be signed by the worker. If the worker wants a written determination with respect to

services performed for two or more firms, a separate form should be furnished for each firm.

Additional copies of this form may be obtained from any Internal Revenue Service office.

U.S, Government Printing Office: 1986—201-993/60208


rom SS-8

(Rev. January 1988)

Department of the Treasury
Internal Revenue Service

Information for Use in Determining Whether a
Worker Is an Employee for Federal
Employment Taxes and Income Tax Withholding

OMB No. 1545-0004
Expires 12-31-90

Paperwork Reduction Act Notice.—We ask for this information
to carry out the Internal Revenue laws of the United States. We
need it to ensure that taxpayers are complying with these laws
and to allow us to figure and collect the right amount of tax. If you
want a determination on employment status, you are required to
give us this information.

Instructions

This form should be completed carefully. If the firm is completing
the form, it should be completed for O| E individual who is
representative of the class of workers whose status is in question.

Ifa written determination is desired for more than one class of
workers, a separate Form SS-8 should be completed for one
worker from each class whose status is typical of that class. A
written determination for any worker will be applicable to other
workers of the same class if the facts are not materially different
from those of the worker whose status was ruled upon.

Please return Form SS-8 to the Internal Revenue Service office
that provided the form. If the Internal Revenue Service did not ask
you to complete this form but you wish a determination on
whether a worker is an employee, file Form SS-8 with your District

irector.

Name of firm (or person) for whom the worker performed services

Name of worker

Address of firm (include street address, city, state, and ZIP code)

‘Address of worker (include street address, city, state, and ZIP code)

Trade name

Telephone number Worker's social security number

Telephone number Firm's taxpayer identification number

Check type of firm

(0 Individual [] Partnership [] Corporation [| Other (specify) >

This form is being completed by © FIRM [] WORKER

If the form is being completed by the worker, do you object to Gisclosing, your name or the information on this form to
the firm? . . sone

(If your answer is YES, we are not able ‘to furnish you a a determination on nthe basis of this form. You may write to your
District Director for further information. Do not complete the rest of the form, unless the IRS requests it.)

All items must be answered or marked “Unknown” or “Not Applicable” (NA). If you need more space, attach another
sheet. This form is designed to cover many work activities, so some of the questions may not pertain to you.

OYes CINo

Total number of workers in this class (if more than one, please see item 19) >

This information is about services performed by the worker from >

What was the first date on which the worker performed services of any kind for the firm? > __

Is the worker still performing services for the firm?
If “No,” what was the date of termination? >

In which IRS district are you located?

la Describe the firm’s business

2a If the work is done under a written agreement between the firm and the worker, attach a copy.
b Ifthe agreement is not in writing, describe the terms and conditions of the work arrangement .._........------------------------

Form SS-8 (Rev. 1-88)


Form SS-8 (Rev. 1-88) Page 2

c

3a

4a

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

Is the worker given training by the firm?. a
If yes:
What kind? ..........
How often?
Is the worker given instructions in the way the work is to be done?
If yes, give specific examples. _
Attach representative copies of any written instructions or procedures.
Does the firm have the right to change the methods used by the worker or direct that person on how to do the work? OYes CNo
Explain your answer _

joes the operation of the firm’s business require that the worker be supervised or controlled in the performance of
theservice?, 2 0 Se ee ee ee ee) | GYes CINo

Explain your answer _

The firm engages the worker:
0 To perform and complete a particular job only.
0 To work at a job for an indefinite period of time.

0 Other (explain)
Is the worker required to follow a routine or a schedule established bythefirm? . . ........... . CYes [CINo
If yes, what is the routine or schedule?

Does the worker report to the firm or its representative

If yes:
How often? __.
For what purpose?
In what manner (in person, in writing,
Attach copies of report forms used in reporting to the firm.

Does the worker furnish atime recordtothefirm?. 2 2 6... ee ee ee ee  » C¥es TNO

If yes, attach copies of time records.

State the kind and value of tools and equipment furnished by:

The firm oe eee ee ee ee ee en nee ee eee eee eee e eee ee een en ee eeneneeeenee

The worker _

State the kind and value of supplies and materials furnished by:
The firm .

Does the firm reimburse the worker foranyexpenses? .. 2... ................. C¥es [No

If yes, specify the reimbursed expenses _

Is it understood that the worker will perform the services personally?. . . ............... CYes [No
Does the worker have helpers?.. . . ran te ee ee ee es. DYes [No
Ifyes: Are the helpers hired by: 1 Firm Oo ‘Worker

If hired by the worker, is the firm's approval necessary?. . . 2...) ee ee ee ee ee Ye CNo
Who pays the helpers? 1] Firm ( Worker

Are social security taxes and Federal income tax withheld from the helpers’ wages?. . . ©. 2 2. ss ee OYes CINo

If yes: Who reports and pays these taxes? [] Firm [1 Worker

Who reports the helpers’ incomes to the Internal Revenue Service? [1 Firm O Worker

If the worker pays the helpers, does the firm repay the worker? - ©. 6 6 6 ee ee ee ..... OYes [No
What services do the helpers perform?



Form SS-8 (Rev. 1-88) Page 3

7 At what location are the services performed? [1 Firm’s [1 Worker's [1 Other (specify) ...........0..0.00.c0e0eeeeeeeeeeee
8a Type of pay worker receives:
OD Salary 0 Commission [1 Hourly wage O) Piecework (1 Lumpsum [1 Other (specify)..................

b Does the firm guarantee a minimum amount of pay tothe worker? . . . oe ee ee ee ee ew)  . G1Yes DINO

¢ Does the firm allow the worker a drawing account or advances againstpay?. .. . ............ DYes [No

If yes: Is the worker paid such advances onaregularbasis?. . . ..........,.....,..... 01¥es (No

How does the worker repay such advances? | __ .

9a Is the worker eligible for a pension, bonuses, paid vacations, sickpay,etc.?. . 6... ......8- . . OY¥es (CINo
If yes specify

b Does the firm carry workmen's compensation insurance onthe worker?. . . . . . see ee... DYes [No

¢ Does the firm deduct social security tax from amounts paidthe worker?. . . . ........=.... =. OYes [JNo

d Does the firm deduct Federal income taxes from amounts paid the worker? . . . 2 2... 1... . . D1¥es [No

e How does the firm report the worker's income to the Internal Revenue Service?
O] Formw-2 0 Form 1099 1 Does not report 1 Other (specify)

f Does the firm bond the worker?,
10a Approximately how many hours a day does: the worker perform services 3s for the firm? Lee

b Does the worker perform similar services for others?. . . . woe ee ee ew... . Yes (No 1 Unknown
If yes: Are these services performed on a daily basis for other firms? tone . . . +. . +()¥Yes [No O Unknown
Percentage of time spent in performing these services for:

This firm . 2.22.2... % Other firms. -% 0 Unknown
Does the firm have priority on the worker's time? Co toe toe »... +. DYes [No
{f no, explain
¢ Is the worker prohi ited from competing with the firm either while performing services or during any later period? - . OYes ONo
11a Can the firm discharge the worker at any time without incurring a liability? . . . . . . ee ee ss. . DYes No
If no, explain

b Can the worker terminate the services at any time without incurringa liability? .............. (Yes [INo

If no, explain. _
12a Does the worker perform services for the firm under:
O The firm's business name O The worker's own business name [1] Other (specify) ...............2..-200-22eeeeeeeeee

b Does the worker advertise or maintain a business listing in the telephone directory, a trade journal, etc.?, (Yes [J No []Unknown
If yes, specify _

Does the worker represent himself or herself to the public as being in business to perform the
sameorsimilarservices? | 2... ee ee ee ee » E1Yes [No (Unknown

d Does the worker have his or her awn shop or office? Foe eee eee ee ee + D1Yes (1 No (Unknown
If yes, where? .

e Does the firm represent the worker as an employee of the firmtoitscustomers?. ............. D)¥es (No
If no, how is the worker represented? .........

f How did the firm learn of the worker's services? _

13 Isalicense necessary forthe work? > 2 2... 2 ee ee ee ee  . Yes [No (Unknown
If yes, what kind of license is required? .__.. 2.2.2.2... eee ee eee eee ee eee eeeee
By whom is it issued?
By whom is the license fee paid?

14 Does the worker have a financial investment in a business related to the services performed? . . . . L1Yes [] No [JUnknown
If yes, specify and give amounts of the investment

15 Can the worker incur a loss in the performance of the service forthefirm? ................ ODYes [No
If yes, NOW? oo... eee eee eee cee cee eee cee eee cece eee ete e eee n cence ce ceeeeeeeceesereeecseceeceeseeseeeeeseeeeeeeeeee

16a Has any other government agency ruled on the status of the firm's workers? . . . . ........... O1Yes [No

If yes, attach a copy of the ruling.
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 recently been considered? .

Ifyes, for which year(s)? ._... 2,-2.2 2.22.2 0- ee eeee cece eee eee ee eee

17 Does the worker assemble or process a product at home or away from the firm's ; place ofbusiness?. .. . . . . .O1 Yes [INo
If yes:
Who furnishes materials or goods used by the worker? [] Firm © Worker
Is the worker furnished a pattern or given instructions to follow in making the product?. . . . . .. .0Yes [INo

|s the worker required to return the finished product to the firm or to someone designated by the firm? .. . .OYes OINo