The information on this form is used to determine whether the individual providing services is
an independent contractor under IRS
guidelines. This form must be completed and signed by the individual performing the services;
reviewed and signed by the individual
responsible for contracting for the services, all prior to any payment for the services.
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| 1. |
Social Security Number (SSN)
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Employer Identification Number (EIN) |
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____-_____ - ______ |
_____ - ____________ |
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Full name of business for the SSN or EIN given above |
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______________________________________________ |
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Business address for tax purposes |
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Street Address: _______________________________ |
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City: _____________________ State: _________________ |
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Zip or Post-Code: ________ Country: _________________ |
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| 2. |
Are you a U.S. citizen or resident alien? __Yes __No |
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If no, country of citizenship: __________________ |
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If non-resident alien; Tax Status : |
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__ Non-exempt.
(These payments may be subject to withholding under Internal Revenue Code section 1441.) |
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___Exempt by virtue of tax treaty. Treaty country _________
(Refer to Financial Policy No. 2319.2.) If exempt under an applicable tax treaty you must complete a Form 8233 and attach it to this certification. |
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| 3. |
Are you an employee of the University of Pennsylvania, HUP or CPUP? __Yes __No |
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If yes, check all that apply |
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__Part-time __Full-time __Faculty
__Other (specify) _______________________ |
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| 4. |
Have you received wages or any other payments from the University of Pennsylvania within the last year? |
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__Yes __No |
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If yes, check the appropriate blank below. If (c), specify the type of payment. |
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(a) __Consulting or other service fee
(b) __Wages
(c) __Other (specify) _________________________ |
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| 5. |
| a. |
I will receive a flat fee for my services. |
__Yes __No |
| b. |
My services are made available to the public on a regular and
consistent basis. |
__Yes __No |
| c. |
I contract with others to provide similar services. |
__Yes __No |
| d. |
I will provide all the required equipment to complete my duties. |
__Yes __No |
| e. |
I have the right to retain others to assist me in carrying out
my duties as assigned. |
__Yes __No |
| f. |
The retention of any such people is solely within my discretion,
and any compensation will be paid by me. |
__Yes __No |
| g. |
I use University classroom or office space to perform my duties. |
__Yes __No |
| h. |
All expenses incidental to the performance of my duties for
the University, including travel expenses are to be borne by me, unless reimbursement is permitted in the
terms of the contract and invoiced with appropriate documentation. |
__Yes __No |
| i. |
I retain the right to schedule the work to be completed. |
__Yes __No |
| j. |
If required, I will submit periodic progress reports to the responsible
department chairman or business administrator as to the status of the project or work being performed. |
__Yes __No |
| k. |
The right to control the progress of the project or work being
performed, is at my discretion. |
__Yes __No |
| l. |
I contract to provide these services on a project-by-project basis.
Nothing in this shall imply that either party has the right or obligation to receive or provide services for any period
other than that covered by the contract. |
__Yes __No |
| m. |
I am providing additional information which may be
relevant to the determination of my status as an independent contractor (e.g. copies of invoices to other customers,
newspaper and/or yellow pages advertisements, business cards, etc).
________________________________________
________________________________________
________________________________________
________________________________________ |
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| 6. |
Certification by independent contractor:
I hereby certify, that I am entitled to claim independent contractor status and that I have complied with all business licensing
requirements. My Philadelphia Business Privilege license no. is ________________. I certify that I pay my own federal,
state, and city income/social security and other taxes in accordance with estimated tax payment requirements. I acknowledge
that, as an independent contractor, I am not eligible for workers compensation, unemployment compensation or other
University employee benefits. I understand that the University will issue a Form 1099-MISC to independent contractors who
receive over six hundred dollars in remuneration during a calendar year. I acknowledge that providing false information will
result in my not being eligible to contract with the University in the future, and may result in further penalties.
Signature: ________________________________
Date: __________
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| 7. |
Business Administrator certification:
I certify that the foregoing statements represent the truth to the best of my knowledge and that all appropriate University
purchasing approvals have been fulfilled. I acknowledge that, if the IRS subsequently determines that employee status should
have applied, all penalties assessed to University of Pennsylvania with respect to this contract may be charged to my
school/department. This certification applies: _____one time ____ for one year from the date of certification.
Signature: _________________________
Title: ________________Date: ________
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| 8. |
Office of the Comptroller approval:
Signature: _________________________
Title: ________________Date: _______
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| 9. |
If not approved, any payment for services must be processed through the payroll system. Refer to HR Policy number 114 or
115 and Financial Policy number 2406.
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