This information is about services performed by the worker from to

Determination of Employee Work Status

for Purposes of Federal Employment Taxes

and Income Tax Withholding

Form SS-8

OMB No. 1545-0004 (Rev. July 1993) Expires 7-31-96 Department of the Treasury

Internal Revenue Service

General Information

This form should be completed carefully. If the firm is completing

the form, it should be completed for ONE individual who is

representative of the class of workers whose status is in question.

If a 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 apply 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 Director.

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

and Medicare taxes or Federal income tax withholding. Also, a

determination that an individual is an employee does not

necessarily reduce any current or prior tax liability. A worker must

file his or her income tax return even if a determination has not

been made by the due date of the return.

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

Address of firm (include street address, apt. or suite no., city, state, and ZIP code) Address of worker (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 taxpayer identification number

Check type of firm for which the work relationship is in question:

Individual Partnership Corporation Other (specify) ©

Yes No

Form SS-8 (Rev. 7-93)

Paperwork Reduction Act Notice

The time needed to complete and file this form will vary

depending on individual circumstances. The estimated average

time is: recordkeeping, 34 hr., 55 min., learning about the law

or the form, 6 min. and preparing and sending the form to

IRS, 40 min. If you have comments concerning the accuracy of

these time estimates or suggestions for making this form more

simple, we would be happy to hear from you. You can write to

both the Internal Revenue Service, Attention: Reports

Clearance Officer, T:FP, Washington, DC 20224; and the Office

of Management and Budget, Paperwork Reduction Project

(1545-0004), Washington, DC 20503. DO NOT send the tax form

to either of these offices. Instead, see General Information for

where to file.

Cat. No. 16106T

We ask for the information on this form to carry out the Internal

Revenue laws of the United States. You are required to give us

this information. We need it to ensure that you are complying

with these laws and to allow us to figure and collect the right

amount of tax.

Purpose

Employers and workers file Form SS-8 to get a determination as

to whether a worker is an employee for purposes of Federal

employment taxes and income tax withholding.

( )

( ) –

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Important Information Needed to Process Your Request

This form is being completed by: Firm Worker

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 answer “Yes,” the IRS cannot act on your request. DO NOT complete the rest of this form unless

the IRS asks for it.

Is there any other information you want removed?

If you check “Yes,” we cannot process your request unless you submit a copy of this form and copies of all

supporting documents showing, in brackets, the information you want removed. Attach a separate

statement telling which specific exemption of section 6110(c) applies to each bracketed part.

This form is designed to cover many work activities, so some of the questions may not apply to you. You must answer ALL

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

Total number of workers in this class. (Attach names and addresses. If more than 10 workers, attach only 10.) ©

(month, day, year)

Is the worker still performing services for the firm?

If “No,” what was the date of termination? ©

Under section 6110 of the Internal Revenue Code, the information on this form and related file documents

will be open to the public if any ruling or determination is made. However, names, addresses, and taxpayer

identification numbers must be removed before the information can be made public.

(month, day, year)

(month, day, year)

Yes No

Yes No
Form SS-8 (Rev. 7–93) Page 2

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

3a Is the worker given training by the firm?

If “Yes”: What kind?

How often?

b Is the worker given instructions in the way the work is to be done (exclusive of actual training in 3a)?

If “Yes,” give specific examples.

c Attach samples 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? 

d

Explain your answer

Does the operation of the firm’s business require that the worker be supervised or controlled in the

performance of the service?

e

4a

Is the worker required to follow a routine or a schedule established by the firm?

c

If “Yes,” what is the routine or schedule?

Does the worker report to the firm or its representative?

d

If “Yes”: How often?

For what purpose?

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

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

Does the worker furnish a time record to the firm?

If “Yes,” attach copies of time records.

5a State the kind and value of tools, equipment, supplies, and materials furnished by:

The firm

The worker

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

c Does the firm reimburse the worker for any expenses?

If “Yes,” specify the reimbursed expenses

6a Will the worker perform the services personally?

b Does the worker have helpers?

If “Yes”: Who hires the helpers? Firm Worker

If hired by the worker, is the firm’s approval necessary?

Who pays the helpers?

Are social security and Medicare taxes and Federal income tax withheld from the helpers’ wages?

If “Yes”: Who reports and pays these taxes?

Who reports the helpers’ incomes to the Internal Revenue Service?

If the worker pays the helpers, does the firm repay the worker?

What services do the helpers perform?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Firm Worker

Firm Worker

Firm Worker

Explain your answer

1a Describe the firm’s business

b Describe the work done by the worker

2a If the work is done under a written agreement between the firm and the worker, attach a copy.

b If the agreement is not in writing, describe the terms and conditions of the work arrangement

b

The firm engages the worker:

To perform and complete a particular job only

To work at a job for an indefinite period of time

Other (explain)
b Does the firm guarantee a minimum amount of pay to the worker?

c Does the firm allow the worker a drawing account or advances against pay? 

If “Yes”: Is the worker paid such advances on a regular basis? 

d How does the worker repay such advances?

9a Is the worker eligible for a pension, bonus, paid vacations, sick pay, etc.? 

If “Yes,” specify

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

c Does the firm deduct social security and Medicare taxes from amounts paid the worker? 

d Does the firm deduct Federal income taxes from amounts paid the worker? 

e How does the firm report the worker’s income to the Internal Revenue Service?

Form W-2 Form 1099-MISC Does not report Other (specify)

f Does the firm bond the worker? 

10a Approximately how many hours a day does the worker perform services for the firm? 

b Does the worker perform similar services for others? Unknown

If “Yes”: Are these services performed on a daily basis for other firms? 

Percentage of time spent in performing these services for:

This firm % Other firms % Unknown

Does the firm have priority on the worker’s time? 

If “No,” explain

Is the worker prohibited from competing with the firm either while performing services or during any later

period? 

c

11a Can the firm discharge the worker at any time without incurring a liability? 

If “No,” explain

b Can the worker terminate the services at any time without incurring a liability? 

12a Does the worker perform services for the firm under:

The firm’s business name The worker’s own business name Other (specify)

Does the worker advertise or maintain a business listing in the telephone directory, a trade

journal, etc.? 

b

If “Yes,” specify

Does the worker represent himself or herself to the public as being in business to perform

the same or similar services? 

c

If “Yes,” how?

d Does the worker have his or her own shop or office? 

e Does the firm represent the worker as an employee of the firm to its customers? 

If “No,” how is the worker represented?

f How did the firm learn of the worker’s services?

13 Is a license necessary for the work? 

If “Yes,” what kind of license is required?

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?

If “Yes,” specify and give amounts of the investment

15 Can the worker incur a loss in the performance of the service for the firm? 

16a Has any other government agency ruled on the status of the firm’s workers? 

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? 

b

If “Yes,” for which year(s)?

Form SS-8 (Rev. 7–93) Page 3

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No Unknown

Yes No Unknown

Yes No Unknown

Yes No Unknown

Yes No Unknown

Yes No Unknown

Yes No

Yes No

Yes No

Yes No

If “No,” explain

Yes No

Yes No

Yes No

Yes No

If “Yes,” where?

If “Yes,” how?

Attach a copy.

If “Yes,” what are the worker’s set hours? am/pm to am/pm (Circle whether am or pm)

8a Type of pay worker receives:

Salary Piecework Commission Hourly wage Lump sum Other (specify)

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

Does the firm set hours of work for the worker? Yes No
Answer items 18a through n only if the worker is a salesperson or provides a service directly to customers.

18a Are leads to prospective customers furnished by the firm? Does not apply

b Is the worker required to pursue or report on leads? Does not apply

c Is the worker required to adhere to prices, terms, and conditions of sale established by the firm? 

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

e Is the worker expected to attend sales meetings? 

If “Yes”: Is the worker subject to any kind of penalty for failing to attend? 

f Does the firm assign a specific territory to the worker? 

g Who does the customer pay? Firm Worker

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

Does the worker sell a consumer product in a home or establishment other than a permanent retail

establishment?

h

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.

i

j Did the firm or another person assign the route or territory and a list of customers to the worker? 

If “Yes,” enter the name and job title of 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?

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.

l

m Does the worker sell life insurance? 

If “Yes”:

Is the selling of life insurance or annuity contracts for the firm the worker’s entire business activity? 

If “No,” list the other business activities and the amount of time spent on them

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

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

At the time the contract was entered into between the firm and the worker, was it their intention that the worker sell life

insurance for the firm: on a full-time basis on a part-time basis

State the manner in which the intention was expressed.

n Is the worker a traveling or city salesperson? 

If “Yes”: From whom does worker principally solicit orders for the firm?

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

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

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

in their business operations, describe the merchandise and state whether it is equipment installed on their premises or a

consumable supply.

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

of the firm.

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 ©

If this form is used by the firm in requesting a written determination, the form must 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 must be signed by the worker. If the worker wants a written determination about services

performed for two or more firms, a separate form must be completed and signed for each firm.

Additional copies of this form may be obtained from any Internal Revenue Service office or by calling 1-800-TAX-FORM (1-800-829-3676).

Form SS-8 (Rev. 7–93) Page 4

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No Does not apply

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

17 Does the worker assemble or process a product at home or away from the firm’s place of business? 

If “Yes”:

Who furnishes materials or goods used by the worker? Worker Firm

Is the worker furnished a pattern or given instructions 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? 

Yes No

Yes No

Yes No