Free UCS-6061 - Florida

Independent Contractor Analysis
NOTE: Complete a separate form for each job title. Attach additional sheets if necessary to explain an answer.

UCS-6061 R. 07/07

This form is to be completed by:

Employing Unit/Business

Worker

Attach copies of any written agreements, billing statements, applications, or contracts between the employing unit and the worker. If the agreement was oral, please reduce it to writing and attach. If any state or federal agency has ruled on the same job class as this worker or another of the same job class, attach a copy of the ruling. (Note: These documents will not be returned.) Worker and Employing Unit: Answer all of the questions. If the worker is still performing services, describe the working arrangement through the current date. If you do not know an answer, write "don't know" next to the question. If a question does not apply, write "n/a" next to the question. If the worker was a sales person, also answer Question 22. Employing Unit: Also answer Question 23. What is the name and address of the employing unit/business? ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What type of work was done by the employing unit/business? ________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What is the name of the worker being investigated? _________________________________________________________ What is the worker's social security number? _______________________________________________________________ What is the worker's federal employer identification number? (if applicable) ____________________________________ What is/was the worker's job class or title? _________________________________________________________________ If the work performed was not part of the employing unit's regular business, how did it differ?_____________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ What dates did the worker perform services for the employing unit/business? __________________________________ Did the employing unit provide Form 1099 or W-2 to the worker for income tax purposes? ____ If yes, specify which form was provided 1099 W-2. Briefly describe the worker's job. __________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ ________________________________________________________________________________________________________

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UCS-6061 R. 07/07 Page 2

While working for the employing unit: 1. 2. 3. 4. 5. 6. 7. 8. 9. Did the worker perform services at the employing unit's place of business? ................................. Could the worker perform services for a competitor of the employing unit? .................................. Did the worker use any of the employing unit's equipment or facilities to do the work? ................ Were the worker's business or travel expenses reimbursed by the employing unit? ...................... Did the worker receive any training from the employing unit? ........................................................ Could the worker sub-contract the job or hire and pay others to do the work? ............................. Did the worker hire and/or supervise other workers?...................................................................... If yes, did the employing unit pay those workers?................................................................... Was there a written contract between the employing unit and the worker? (If yes, provide a copy) . Were there set hours of work? ......................................................................................................... A) When to do the work?.......................................................................................................... B) How to do the work? ........................................................................................................... 11. Could the worker provide his/her services outside of the employing unit's regular business hours? 12. Was the worker required to keep the employing unit informed of the progress of the work?......... 13. Did the worker bill the employing unit for services performed? (If yes, submit a copy) .................. 14. Was the worker paid by: A) Time? (hourly, weekly, or monthly) ....................................................................................... B) Salary? ................................................................................................................................. C) Commission? ....................................................................................................................... D) The Job? .............................................................................................................................. 15. Did the employing unit provide: A) Health or life insurance? ...................................................................................................... B) Vacation, holiday, or sick pay? ............................................................................................ C) Retirement benefits?............................................................................................................ D) Workers' Compensation coverage? .................................................................................... E) Bonuses? ............................................................................................................................. 16. Did the employing unit direct the sequence in which the work must be done? .............................. 17. Was the worker supervised by an employee of the employing unit? .............................................. 18. Was the worker in business for himself/herself? ............................................................................. A) If yes, did the worker have a financial investment in the business? .................................... B) If yes, did the worker advertise to the general public? ........................................................ C) If yes, did the worker carry business liability insurance? .................................................... 19. Could the worker quit or be discharged at any time without a breach of contract penalty? .......... 20. Was the worker responsible for redoing defective work without additional compensation?............ 21. Do you believe the worker was an employee or
Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No Yes Yes Yes Yes No No No No Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes Yes No No No No No No No No No No No No No No No

10. Did the employing unit give the worker instructions about:

independent contractor? Explain the reason for this belief.

_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________

UCS-6061 R. 07/07 Page 3

22. IF THE WORKER WAS A SALESPERSON, ALSO ANSWER THESE QUESTIONS. A) Did the worker: 1) Solicit orders for business supplies or merchandise for resale? .................................................. 2) Sell consumer products/services directly to buyers on a buy-sell, deposit-commission or similar basis? ............................................................................................................................ 3) Perform services as an insurance or real estate agent or solicitor? ............................................. B) Did the worker sell full-time for the employing unit? ........................................................................ C) Could the worker concurrently sell for a competitor of the employing unit? .................................... D) Was the worker required to make a business investment other than travel expenses and transportation?.................................................................................................................................. E) Would the worker be penalized for not attending sales meetings? .................................................. 23. ITEMS A ­ G BELOW ARE TO BE COMPLETED ONLY BY THE EMPLOYING UNIT/BUSINESS A) Unemployment Tax (UT) Account Number of Employing Unit (if applicable): _________________________________ B) Form of Organization: Sole Proprietorship, Partnership, Corporation, Other (specify) _______________ ____________________________________________________________________________________________________ C) Total number of workers in this class considered independent contractors. __________________________________ D) Total number of workers in this class considered employees. ______________________________________________ E) If a number was entered for C) and D), explain the difference between the independent contractors and employees. __________________________________________________________________________________________ F) When did a worker in this job class first perform services of any kind for the employing unit/business? ____________________________________________________________________________________________________ G) Do all workers in this class who are considered independent contractors perform services under the same terms and conditions? ................................................................................................................................ Yes No (explain any differences) ______________________________________________________________________________ ____________________________________________________________________________________________________ I reviewed this completed questionnaire, including any accompanying documents, and to the best of my knowledge and belief, the information provided is true and correct. I understand that knowingly providing false or misleading statements to the Department of Revenue is punishable as a third degree felony pursuant to Section 443.071, Florida Statutes. Employing Unit/Business Representative Signature ___________________________________________________________ Title ____________________________________________________________________________________________________ Date ______________________________________ Telephone Number _______________________________________
Yes Yes Yes Yes Yes Yes Yes No No No No No No No

Worker Signature ________________________________________________________________________________________ Date ______________________________________ Telephone Number _______________________________________

Field Auditor or Claims Investigator Signature _______________________________________________________________ Date ______________________________________