Form SS-8 (Rev. 1-85) Page 4

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

18a
18b
18¢
18d
18e

18f
18g

18h
18

18)

18k

18!

18m

18n

19

20

Are leads to prospective customers furnished bythefirm?. . ........... .C) Yes 11 No UC Doesnot apply
Is the worker required to pursue or reportonieads? . . . . sae es. sO Yes 1] No ( Doesnot apply
Is the worker required to adhere to prices, terms, and conditions of sale established bythefirm?. ...... . DYes [No
Are orders submitted to and subject to approvalbythefirm? . . 2... 6... 4.4... 4.4... Yes [No
Is the worker expected to attend sales meetings? . . . Soe ee ee ee ee ew . DYes LI No
if yes: Is the worker subject to any kind of penalty for failing to attend? we ee eee ee ee ee . OYes ONO
Does the firm assign a specific territory tothe worker? . . . . . ....... .. -2) Yes C1 No OC Does not apply
Who does the customer pay? 1] Firm (1 Worker

If worker, does the worker remit the totalamounttothefirm?. . . ...... toe ... OYes O1No

Does the worker sell a consumer product in a home or establishment other than a permanent retail establishment? . OYes CNo
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.

Were the route or territory and a list of customers assigned to the worker by the firm or another person? . . . . . C1Yes LINo
If yes, please identify the person who made the assignment. .
Did the worker pay the firm or person for the privilege of serving customers on the route or in the ‘territory? .... OY¥es ONo

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..

Does the workerselllifeinsurance? . 2 2... ee ee ee ee eee es» OVes 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
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 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..
Is the worker either 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 wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar
establishments, specify the percentage of the worker's time spent in such solicitation. ......... %
Is 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.

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.

If the only items you want deleted are names, addresses, and taxpayer identifying numbers, please checkthisbox . . . . .O

If you believe additional deletions should be made, please 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 6610(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 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 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 statement should be furnished for each firm.
Additional copies of this form may be obtained from any Internal Revenue Service office.



rom SSB

(Rev. January 1985)

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 2-29-88

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 ONE 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

rector.

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

Address of firm ‘Address of worker

Trade name Telephone number Worker's social security number
Telephone number Firm’s taxpayer identification number

Check type of firm

C1 Individual [) Partnership [] Corporation [| Other (specify) >

This form is being completed by 1 FIRM [] 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? . . . soe .

see ss » OY¥es DNo

(If your answer is YES, we are not able to 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.

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

This information is about services performed by the worker from >

(Month, day, year)

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

Is the worker still performing services forthe firm? . . . . .
If ‘No,"’ what was the date of termination? >»

In which IRS district are you located?

-CYes (1 No

la

1b

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

2b If the agreement is not in writing, describe the terms and conditions of the work arrangement

Form SS-8 (Rev. 1-85)


Form $S-8 (Rev. 1-85)

2c

3b

3c
3d

3e

4a

4b

4c

4a

5a

5b

5c

5d

6a
6b

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

Is the worker giventraining bythefirm?, . 6 6. 0. ee ee ee ee ee ee ee ees  . Des LINO
If yes:

What kind? ..._.

How often? _____
Is the worker given instructions in the way the work is to be done? Se ee ee ee ee eee. Ges LINO

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 todo the work? ~LlYes [No
Explain your answer

Does the operation of the firm's business require that the worker be supervis ed or controlled in the performance of
the service? .
Explain your answer

The firm engages the worker for:
O Particular job 1 Indefinite period 1 Other (explain)
Is the worker required to follow a routine or a schedule established bythefirm? .........,..... OYes CINo
If yes, what is the routine or schedule?

Does the worker report to the firm or its representative? _ . . .
If yes:
How often? _.. 2.2.2...
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 atime recordtothefirm? . 2. 6 6 6 ee ee ee ee ee ee  ~ DYes [No
If yes, attach copies of time records.
State the kind and value of tools and equipment furnished by:
The firm

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

Does the firm reimburse the worker for anyexpenses? » 2... 1... ee ee ee ee es « CYes LINO

If yes, specify the reimbursed expenses

Is it understood that the worker will perform the services personally? . . . ............... C1¥es [No
Does the workerhavehelpers?. 2. 6 ee ee ee ee ee ee» GYes FINO
Ifyes: Are the helpers hired by: CJ Firm ( Worker

If hired by the worker, is the firm’s approval necessary?. . . 2... 2 ee ee ee ee ee ee. OYes [INO
Who pays the helpers? (1 Firm [1 Worker

Are social security taxes and Federal income tax withheld from the helpers’ wages?. . . . ..... =... . DlYes [DINo

If yes: Who reports and pays these taxes? CL] Firm [] Worker
Who reports the helpers’ incomes to the Internal Revenue Service? CI Firm (1 Worker

If the worker pays the helpers, does the firm repaythe worker? . . . 1... 1 ee ew ee ew ee ~~ DYes [No
What services do the helpers perform?



Form SS-8 (Rev. 1-85) Page 3

7 Atwhat location are the services performed? [1 Firm’s [] Worker's (1 Other (specify) .
8a Type of pay worker receives:
OO Salary © Commission [© Hourly wage O Piecework O Lumpsum O Other (specif)

8b Does the firm guarantee a minimum amount of paytotheworker?. . 2... ww ee OYes CINo
8c Does the firm allow the worker a drawing account or advances against pay?. . . 2 2 1 1 ee ee ee . . DYes [INo
If yes: Is the worker paid such advances on a regular basis?.

How does the worker repay such advances? _..
9a Is the worker eligible for a pension, bonuses, paid vacations,

ick pay, etc.

If yes (specify) . 2.2.22... cece eee ee eee eee eee eee eee wees
9b Does the firm carry workmen’s compensation insurance on the worker?.. . . . wee ee eee. Des DINO
9c Does the firm deduct social security tax from amounts paidtheworker?. . . . 1... 2...) ~~ DYes LINo
9d_ Does the firm deduct Federal income taxes from amounts paid the worker? . . . 1... 1... CYes CINo

Qe How does the firm report the worker's income to the Internal Revenue Service?
O Formw-2 01 Form 1099 C1 Doesnotreport (1) Other (speci)

9f Does the firm bond the worker?. :
10a Approximately how many hours a day does the worker perform se services for the: firm?

10b Does the worker perform similar services for others? . . . . ry OYes OINo (Unkown
If yes: Are these services performed ona daily basis for other firms? te ee . +.» .D¥Yes [No ([Unkown
Percentage of time spent in performing these services for:
This firm __.......5 % Other firms__ --% OO Unkown
Does the firm have priority on the worker’ s time? ee OYes CINo
If no, explain

10c Is the worker prohibited from competing with the firm either while performing services or during any later period?. . ClYes ([INo

11a Can the firm discharge the worker at any time without incurringa liability? . 2... 1. ee ee ee OYes CINo
If no, explain .

11b Can the worker terminate the services at any time without incurringa liability? .............. OY¥es [No
If no, explain

12a Does the worker perform services for the firm under:
0 The firm's business name OO The worker's own businessname [] Other (specify) ...

12b Does the worker advertise or maintain a business listing in the telephone directory, a trade journal, et OYes [No (J) Unkown
Ifyes, specify oo... 2. eee eee cece eee cece eee eee ee ee eee

12c Does the worker represent himself or herself to the public as being in business to perform the
same or similar services? hee

12d Does the worker have his or her own shop or office?
If yes, where?
12e Does the firm represent the worker as an employee of the firm toitscustomers?. . . .. 2... ...... OYes CINo
If no, how is the worker represented? .........
12f How did the firm learn of the worker's services? _
13 Isalicense necessary forthework? . 2. 2... ee ee ee ee ee ee ~~ Yes ONo Unkown
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? . . . . L1Yes [JNo []Unkown
If yes, specify and give amounts of the investment

15 Canthe worker incur a loss in the performance of the service forthe firm? ................ C)¥es [JNo
If yes, how?

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

If yes, attach a copy of the ruling.
16b 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 2 2-1 ee ee ee sees.» OY¥es CNo
If yes, for which year(s)?
17a Does the worker assemble or process a product at home or away from the firm’s place ofbusiness?. . . . . . . .(.Yes [CINo

If yes:
Who furnishes materials or goods used by the worker? CJ Firm (1 Worker
Is the worker furnished a pattern or given instructions to followin making the product?. . . . ... .O1Yes [No
Is the worker required to return the finished product to the firm or to someone designated by the firm? ... .DYes ONo