Form $S-8 (Rev. 10-90) Page 4

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

18a Are leads to prospective customers furnished bythe firm?. ............ .()Yes C1No [1 Doesnot apply
b Is the worker required to pursue or reportonleads? . . . . . . . . .()Yes [JNo [) Doesnot apply

c Is the worker required to adhere to prices, terms, and conditions ‘of sale established by thefim?. ....... OYes ONo

d Are orders submitted to and subject to approval bythefirm? . 2 6 6 6 we D Yes [No
e Is the worker expected to attend sales meetings? . . . Se ee ee ee ee ee . Yes ONO
If “Yes”: Is the worker subject to any kind of penalty for failing: to ‘attend? Se ee ee ee ee ee. . DYes ONO

f Does the firm assign a specific territory tothe worker? . . 2 . . 1... . . . . « -O Yes CINo J Doesnot apply

Who does the customer pay? C1 Firm (1 Worker

If worker, does the worker remit the total amount tothe firm?. . . . oo ...... OYes ONo

hh Does the worker sell a consumer product in a home or establishment other than a a permanent retell establishment? . OYes ONo

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. o.oo... e eee cece cece eee ecec eee eceeceeeeceeeeeeee
Did the firm or another person assign the route or territory and a list of customers to the worker:
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? . . . . C1 Yes CINo

If “Yes,” how much did the worker pay (not including any amount paid for a truck or racks, etc.)? $_

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. -........ 22-2... -220 222 e eee eee ee cee eee eee eee eee ee ee eee ence nena eeeeeneee

m Does theworkerselllifeinsurance? 2 2 2. 2 ee ee ee ee es » Ves ONO
If “Yes”:
Is the selling of life insurance or annuity contracts for the firm the worker's entire business activity? . . . . . C1Yes CINo

If “No,” state the extent of the worker's other business activities ..............2---2-2-2-2eeeecec sence eect et eeeceseeeeeeeeteee
Does the worker sell other types of insurance for the firm? . :

If “Yes,” state the percentage of the worker's total working time spent i in selling: such ‘other types of i 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: 1 ona full-timebasis 1 ona part-time basis

State the manner in which such intention was expressed.

n_ Is the worker a traveling salesperson orcitysalesperson? . . . 1... 2...) ee ee + Yes ONO

19

20

If “Yes”:
Specify from whom the worker principally solicits orders on behalf of the firm. .........222---20.22eeeeeee cece e cece eeeeeeeceeee
\f 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 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 installed on their premises or
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 CINo
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, I 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.

It

his 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 Otfice: 1992 — 349-034/60171


rom S9°B

(Rev. October 1990)

Department of the Treasury
Internal Revenue Service

Determination of Employee Work Status
for Purposes of Federal Employment Taxes
and Income Tax Withholding

OMB No. 1545-0004
Expires 10-31-93

Paperwork Reduction Act Notice.—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.

The time needed to complete and file this form will vary
depending on individual circumstances. The estimated average
time is: recordkeeping, 34 hrs., 41 mi arning about the law
orm, 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, Washington, DC 20024, Attention: IRS
Reports Clearance Officer, T:FP, 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 the instructions for information on
where to file.

Instructions
This form should be completed carefully. If the firm is completing
the form, it should be completed for ONE individual whois _
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 wil 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 tyou wish a determination on whether
a worker is an employee, file Form SS-8 with your District Director.
Cautlon: Form SS-8 is not a claim for refund of social security tax
or Federal income tax withholding. Also, a determination that an
individual is an employee does not necessarily reduce any current
or prior tax liability.

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 Worker's social security number
Telephone number Firm’s taxpayer identification number 1] RM_m Y il y 7

Check type of firm:

Individual [Partnership [Corporation [1 Other (specify) >

This form is being completed by: 1 FIRM 1 WORKER

If the form is being completed by the worker, do you object to disclosing your name or the information on this form to
thefirm? 2
(If your answer is “Yes,” we cannot furnish you a determination on the 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 C1No

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 > to.

(Month, day, year)

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

(Month, day, year)

0 Yes

Js the worker still performing services forthe firm? 2... 6 ee ee ee ee 01 No
If ‘‘No,”’ what was the date of termination? >

In which IRS district are you located?

la 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 _

Cat. No. 16106T Form SS-8 (Rev. 10-90)


Form $S-8 (Rev. 10-90) Page 2

c

3a

°

4a

5a

6a

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? .
If “Yes”:
What kind?
How often: -
Is the worker given instructions in the way the workistobedone?. . . . 2... ........... DYes [No
If “Yes,” give specific examples. __. 2.22.2... eee cece cee eee eee eee ee eee ee eee ee eee eee cece eee ee eeeneee
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 todo the work? ~(lYes [No
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? .
Explain your answer

The firm engages the worker:
O To perform and complete a particular job only
0 To work at a job for an indefinite period of time
O Other (explain) ...
Is the worker required to follow a routine or a schedule established by thefirm? .............. DCY¥es DINo
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, by telephone, etc.)? 0.2.02... c ee eee eee eee eee eee eee eee eee eee eee
Attach copies of report forms used in reporting to the firm.

Does the worker furnish atime record tothe firm? . 6 6... we ee ee ee » G¥es LINO

If “Yes,” attach copies of time records.

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

The firm

The worker

State the kind and value
The firm

of supplies and materials furnished b:

The worker

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

Does the firm reimburse the worker forany expenses? . 2 2... 1. ee ee ee es . » DXYes [NO

If “Yes,” specify the reimbursed expenses

Will the worker perform the services personally? . . 2... 1 1. eee ee ee ee ee ee . Yes ONO
Does the worker have helpers? . So ee . . . aa . OYes ONo
If “Yes”: Are the helpers hired by: [11 Firm () Worker

If hired by the worker, is the firm's approval necessary?. . 2. 2... ee ee ee ee ww es  . Yes ONO
Who pays the helpers? C] Firm ( Worker

Are social security taxes and Federal income tax withheld from the helpers’ wages?. . . . ....... =.=. DYes ONo

If “Yes”: Who reports and pays these taxes? C] Firm [1 Worker
Who reports the helpers’ incomes to the Internal Revenue Service? O Firm © Worker
If the worker pays the helpers, does the firm repay the worker? . . . . . 1... 1... ..... OYes ONo



Form $S-8 (Rev. 10-90) Page 3

7 ‘At what location are the services performed? O Firm’s © Worker's [1 Other (specify) ..0.000..0 0000.20 0c eceeeeee eee eee

8a Type of pay worker receives:
O Salary O Commission (©) Hourly wage © Piecework () Lumpsum (1 Other (specify)..................

b Does the firm guarantee a minimum amount of pay tothe worker?. 2. 1 2 ww we Yes [JNo
¢ Does the firm allow the worker a drawing account or advances againstpay?. .. ............. DYes (No
If “Yes”: Is the worker paid such advances onaregularbasis? ................. 4... CYes [No

d How does the worker repay such advances? ............
9a Is the worker eligible for a pension, bonuses, paid vacations, sick pay, etc.? .
If “Yes,” specify
b Does the firm carry workmen's compensation insurance on the worker? .
¢ Does the firm deduct social security tax 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?
O Formw-2 Cl) Form1099 (1 Doesnotreport Other (specify)
f Does the firm bond the worker?. . te
10a Approximately how many hours a day does the worker perform services for the: firm? nee e eee ee eee e nce c cee eeneeeeeeeeseeeeeeeeeeee

b Does the worker perform similar services for others?. . . . toe ee ae ee . . . Yes [No 1 Unknown
If “Yes”: Are these services performed on a daily basis for other firms? sone ee eee ee « «Yes [No 0 Unknown
Percentage of time spent in performing these services for:

This firm .........5 % Other firms, .. % O Unknown
Does the firm have priorityon the worker'stime? 2. 2 6 6 1 2. ee ee ee ee ee ee ee ee FYes LJNO
If “No,” explain,
¢ Is the worker prohibited from competing with the firm either while performing services or during any later period’ OYes [INo
la Can the firm discharge the worker at any time without incurringaliability?. ............... (Yes [No
If “No,” explain. ... 0.2... e eee cee ence cee cee e ee eee eee eee eee en ee ee eee e ee ee en eeeeeeeeeeenececcseceeeeeees

b Can the worker terminate the services at any time without incurring a sia OYes [JNo

If “No,” explain... . 2... eee eee eee eee een erence ee eee nee nee eee eee e ee ee enn ee eect ececreeeeseeeneeeesceeeaesenes
12a Does the worker perform services for the firm under
0 The firm’s business name 1 The worker's own businessname (1) Other (specify) ............2222----2222ceeeee ee eee

b Does the worker advertise or maintain a business listing in the telephone directory, a trade journal, etc.? OyYes CNo 0 Unknown
If “Yes,” specify
¢ Does the worker represent himself or herself to the public as being in business to perform the
same or similar services? Se eee ee ee ee es . » Yes CNo 0 Unknown

f How did the firm learn of the worker's services?
13 Isa license necessary for the work?

By whom is the license fee paid’

14 Does the worker have a financial investment in a business related to the services performed? . . . .C)Yes CINo CL] Unknown
If “Yes,” specify and give amounts of the investment
15 Can the: worker incur a loss in the performance of the service forthefirm? ................ 0)Yes [INo

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

If “Yes,” attach a copy of the ruling.
b 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 beenconsidered?. . . . 2 2... ee ee eee ee ee es» Ces CINO
If “Yes,” for which year(s)? ......... 222-22 eeee eee cece eee ee ee cece ee ee ee ence eee een e eee eee e ene necececeneeneneeeeceeeneeeeee
17 Does the worker assemble or process a product at home or away from the firm's place of business?. . . . . . . .C)Yes [IJNo
If “Yes”:
Who furnishes materials or goods used by the worker? [] Firm O Worker
Is the worker furnished a pattern or given instructions to follow in making the product?. . . . . ... .O)Yes [No

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