Independent Contractor Application – Fill Out and Use This PDF

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Independent Contractor Application – Fill Out and Use This PDF

The Independent Contractor Application is a form for independent contractors to complete.

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Independent Contractor Application PDF Details

Are you looking for a new opportunity as an independent contractor? If so, you'll want to complete the Independent Contractor Application Form. This form is used by businesses to assess your qualifications and determine if you are a good fit for an open position. Completing the form accurately and thoroughly will help ensure that your application is considered. Be sure to include all relevant information, including your skills and experience.

This information will help you comprehend better the details of the independent contractor application before you begin filling it out.

Question	Answer
Form Name	Independent Contractor Application
Form Length	15 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	3 min 45 sec
Other names	contractor application form, 31st, Wyoming, Cosmetology

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FOR OFFICIAL USE ONLY

Date Received:_______/_______/__________

Reviewed by:___________________________________________

Comments:_____________________________________________

________________________________________________________

INDEPENDENT CONTRACTOR APPLICATION

Applications are considered for all independent contractors, and contractors are treated during the agreement, without regard to race, color, religion, sex, national origin, age, disability, or any other prohibited basis of discrimination as provided under applicable state and federal law.

Position(s) Applying For:__________________________________________________________________________________________

BACKGROUND INFORMATION

Name:__________________________________________________________________________________________________________

Street Address:__________________________________________________________________________________________________

City:________________________________ State:_______________________________ Zip:_________________________________

Phone:______________________________ Fax:________________________________ Email:_______________________________

Type of Entity (e.g., individual, corporation, partnership, etc):________________________________________________________________

Description of Primary Business:___________________________________________________________________________________

SIC (if business)_______________________________ SSN (if individual)_____________________________ EIN (if business)_______________________________

Products/Services Offered (check all that apply):
□ Consulting	□ Professional	□ Other

CONTRACTING REQUEST

Anticipated Rates: $_____________________________________________________________________________________________

Hours Available per Week:_______________________________________________________________________________________

What is the earliest date you can begin work?:___________________________________________________________________

PROFESSIONAL REFERENCES

Name:	Company:	Position:	Contact Info:
___________________________	___________________________	___________________________	___________________________
___________________________	___________________________	___________________________	___________________________
___________________________	___________________________	___________________________	___________________________

PREVIOUS POSITIONS (Please begin with most recent)

Company:__________________________ Phone:______________________________ Contact:____________________________

Address:________________________________________________________________________________________________________

Employment Dates:	Pay or Salary:	Reason for leaving:	Position & Duties
From_______________________	Start_______________________	___________________________	___________________________
To_ ________________________	Final_______________________	___________________________	___________________________

Company:__________________________ Phone:______________________________ Contact:____________________________

Address:________________________________________________________________________________________________________

Employment Dates:	Pay or Salary:	Reason for leaving:	Position & Duties
From_______________________	Start_______________________	___________________________	___________________________
To_ ________________________	Final_______________________	___________________________	___________________________

Company:__________________________ Phone:______________________________ Contact:____________________________

Address:________________________________________________________________________________________________________

Employment Dates:	Pay or Salary:	Reason for leaving:	Position & Duties
From_______________________	Start_______________________	___________________________	___________________________
To_ ________________________	Final_______________________	___________________________	___________________________

EXISTING CONTRACTUAL RELATIONSHIPS (Please list all current independent contractor relationships)

Company:______________________________________________________________________________________________________

Address:____________________________	Obligations:_________________________	Industry Type:_ ______________________
____________________________________	____________________________________	____________________________________
Phone:______________________________	Effective Date:______________________	Monthly Hours Worked:______________
Contact:____________________________	End of Term:________________________	____________________________________

Company:______________________________________________________________________________________________________

Address:____________________________	Obligations:_________________________	Industry Type:_ ______________________
____________________________________	____________________________________	____________________________________
Phone:______________________________	Effective Date:______________________	Monthly Hours Worked:______________
Contact:____________________________	End of Term:________________________	____________________________________
Company:______________________________________________________________________________________________________
Address:____________________________	Obligations:_________________________	Industry Type:_ ______________________
____________________________________	____________________________________	____________________________________
Phone:______________________________	Effective Date:______________________	Monthly Hours Worked:______________
Contact:____________________________	End of Term:________________________	____________________________________

ADDITIONAL INFORMATION

Are you legally eligible for work in the U.S.A.?	□	Yes (verification required)	□	No
Have you ever contracted with HHA before?	□	Yes	□	No

If yes, when? (Please attach previous contract application)_________________________________________________________________

Do you have liability and/or malpractice insurance?

□ Yes

□ No

If yes, please attach proof of insurance to application.

Do you agree to obtain any and all licenses that may be
required to do business as an independent contractor or
self-employed person?	□	Yes	□	No
Do you understand that as an independent contractor,
you would not be eligible for unemployment benefits at
the end of any contract with HHA?	□	Yes	□	No
Do you understand that as an independent contractor,
you would be responsible for payment of any and all
state and/or federal income taxes, Social Security,
self-employment taxes, unemployment taxes, and
payroll taxes and you will receive a form 1099 for
service provided to HHA by you?	□	Yes	□	No

SIGNATURE/CERTIFICATION

I certify that the facts set forth in this application are true, complete, and correct to the best of my knowledge. I understand that any misrepresentations, falsifications, or omissions on this application can be grounds for immediate denial of my appointment or removal from consideration or, if I have entered into a contract with this company, for immediate termination of that contract. I authorize HHA to make any necessary inquiries and investigations into my education, references, or employment history. I further authorize, unless otherwise indicated on this application, the release of my information to HHA by any of the schools, services, or employers listed on this application.

I also hereby release from liability HHA and its representatives for seeking, gathering, and using such information to make decisions concerning my status as an independent contractor for HHA and all other persons or organizations for providing such information.

THIS IS NOT AN APPLICATION FOR EMPLOYMENT. I understand and agree that if this application is accepted, my status will be that of an independent contractor and as such, I will be solely responsible for all tax liabilities pertaining to monies received in the course of services I perform.

If I am retained by HHA as an independent contractor I will:

•Not be entitled to workers compensation benefits.

•Not be entitled to unemployment insurance benefits unless unemployment coverage is provided by me or some other entity.

•Be obligated to pay federal and state income tax on any moneys paid pursuant to the contract.

•Be required to provide professional and liability insurance.

I represent and warrant that I have read and fully understand the foregoing, and that I seek to become and independent contractor under these conditions.

Signature:_______________________________________________________________________Date:_______/_______/__________

	Employment Eligibility Verification	USCIS
	Department of Homeland Security	Form I-9
	Department of Homeland Security	OMB No. 1615-0047
	U.S. Citizenship and Immigration Services	OMB No. 1615-0047
	U.S. Citizenship and Immigration Services	Expires 08/31/2019

►START HERE: Read instructions carefully before completing this form. The instructions must be available, either in paper or electronically, during completion of this form. Employers are liable for errors in the completion of this form.

ANTI-DISCRIMINATION NOTICE: It is illegal to discriminate against work-authorized individuals. Employers CANNOT specify which document(s) an employee may present to establish employment authorization and identity. The refusal to hire or continue to employ an individual because the documentation presented has a future expiration date may also constitute illegal discrimination.

Section 1. Employee Information and Attestation (Employees must complete and sign Section 1 of Form I-9 no later than the first day of employment, but not before accepting a job offer.)

Last Name (Family Name)

First Name (Given Name)

Middle Initial

Other Last Names Used (if any)

Address (Street Number and Name)

Apt. Number

City or Town

State

ZIP Code

Date of Birth (mm/dd/yyyy)

U.S. Social Security Number

- -

Employee's E-mail Address

Employee's Telephone Number

I am aware that federal law provides for imprisonment and/or fines for false statements or use of false documents in connection with the completion of this form.

I attest, under penalty of perjury, that I am (check one of the following boxes):

1.	A citizen of the United States

2.	A noncitizen national of the United States (See instructions)

3.	A lawful permanent resident	(Alien Registration Number/USCIS Number):


4.	An alien authorized to work	until (expiration date, if applicable, mm/dd/yyyy):

Some aliens may write "N/A" in the expiration date field. (See instructions)

Aliens authorized to work must provide only one of the following document numbers to complete Form I-9:

An Alien Registration Number/USCIS Number OR Form I-94 Admission Number OR Foreign Passport Number.

1.Alien Registration Number/USCIS Number:

2.Form I-94 Admission Number:

3.Foreign Passport Number: Country of Issuance:

QR Code - Section 1

Do Not Write In This Space

Signature of Employee	Today's Date (mm/dd/yyyy)

Preparer and/or Translator Certification (check one):

I did not use a preparer or translator.

A preparer(s) and/or translator(s) assisted the employee in completing Section 1.

(Fields below must be completed and signed when preparers and/or translators assist an employee in completing Section 1.)

I attest, under penalty of perjury, that I have assisted in the completion of Section 1 of this form and that to the best of my knowledge the information is true and correct.

Employer Completes Next Page

Form I-9 07/17/17 N

Page 1 of 3

	Employment Eligibility Verification	USCIS
	Department of Homeland Security	Form I-9
	Department of Homeland Security	OMB No. 1615-0047
	U.S. Citizenship and Immigration Services	OMB No. 1615-0047
	U.S. Citizenship and Immigration Services	Expires 08/31/2019

Section 2. Employer or Authorized Representative Review and Verification

(Employers or their authorized representative must complete and sign Section 2 within 3 business days of the employee's first day of employment. You must physically examine one document from List A OR a combination of one document from List B and one document from List C as listed on the "Lists of Acceptable Documents.")

Employee Info from Section 1	Last Name (Family Name)	First Name (Given Name)	M.I. Citizenship/Immigration Status
Employee Info from Section 1

List A	OR	List B	AND	List C
Identity and Employment Authorization		Identity		Employment Authorization

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title

Issuing Authority

Document Number

Expiration Date (if any)(mm/dd/yyyy)

Document Title		Document Title

Issuing Authority		Issuing Authority

Document Number		Document Number

Expiration Date (if any)(mm/dd/yyyy)		Expiration Date (if any)(mm/dd/yyyy)


	Additional Information		QR Code - Sections 2 & 3
	Additional Information		Do Not Write In This Space
			Do Not Write In This Space

Certification: I attest, under penalty of perjury, that (1) I have examined the document(s) presented by the above-named employee,

(2)the above-listed document(s) appear to be genuine and to relate to the employee named, and (3) to the best of my knowledge the employee is authorized to work in the United States.

The employee's first day of employment (mm/dd/yyyy):

(See instructions for exemptions)

Signature of Employer or Authorized Representative

Today's Date (mm/dd/yyyy)

Title of Employer or Authorized Representative

Last Name of Employer or Authorized Representative

First Name of Employer or Authorized Representative

Employer's Business or Organization Name

Employer's Business or Organization Address (Street Number and Name)

City or Town

State

ZIP Code

Section 3. Reverification and Rehires (To be completed and signed by employer or authorized representative.)

A. New Name (if applicable)			B. Date of Rehire (if applicable)
Last Name (Family Name)	First Name (Given Name)	Middle Initial	Date (mm/dd/yyyy)

C. If the employee's previous grant of employment authorization has expired, provide the information for the document or receipt that establishes continuing employment authorization in the space provided below.

Document Title

Document Number

Expiration Date (if any) (mm/dd/yyyy)

I attest, under penalty of perjury, that to the best of my knowledge, this employee is authorized to work in the United States, and if the employee presented document(s), the document(s) I have examined appear to be genuine and to relate to the individual.

Signature of Employer or Authorized Representative	Today's Date (mm/dd/yyyy)

Name of Employer or Authorized Representative

Form I-9 07/17/17 N

Page 2 of 3

LISTS OF ACCEPTABLE DOCUMENTS

All documents must be UNEXPIRED

Employees may present one selection from List A

or a combination of one selection from List B and one selection from List C.

LIST A	LIST B	LIST C
Documents that Establish	Documents that Establish	Documents that Establish
Both Identity and	Identity	Employment Authorization
Employment Authorization	OR	AND

1.U.S. Passport or U.S. Passport Card

2.Permanent Resident Card or Alien Registration Receipt Card (Form I-551)

3.Foreign passport that contains a temporary I-551 stamp or temporary I-551 printed notation on a machine- readable immigrant visa

4.Employment Authorization Document that contains a photograph (Form I-766)

5.For a nonimmigrant alien authorized to work for a specific employer because of his or her status:

a.Foreign passport; and

b.Form I-94 or Form I-94A that has the following:

(1)The same name as the passport; and

(2)An endorsement of the alien's nonimmigrant status as long as that period of endorsement has not yet expired and the proposed employment is not in conflict with any restrictions or limitations identified on the form.

6.Passport from the Federated States of Micronesia (FSM) or the Republic of the Marshall Islands (RMI) with Form I-94 or Form I-94A indicating nonimmigrant admission under the Compact of Free Association Between the United States and the FSM or RMI

1.Driver's license or ID card issued by a State or outlying possession of the United States provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

2.ID card issued by federal, state or local government agencies or entities, provided it contains a photograph or information such as name, date of birth, gender, height, eye color, and address

3.School ID card with a photograph

4.Voter's registration card

5.U.S. Military card or draft record

6.Military dependent's ID card

7.U.S. Coast Guard Merchant Mariner Card

8.Native American tribal document

9.Driver's license issued by a Canadian government authority

For persons under age 18 who are

unable to present a document

listed above:

10.School record or report card

11.Clinic, doctor, or hospital record

12.Day-care or nursery school record

1.A Social Security Account Number card, unless the card includes one of the following restrictions:

(1)NOT VALID FOR EMPLOYMENT

(2)VALID FOR WORK ONLY WITH INS AUTHORIZATION

(3)VALID FOR WORK ONLY WITH DHS AUTHORIZATION

2.Certification of report of birth issued by the Department of State (Forms DS-1350, FS-545, FS-240)

3.Original or certified copy of birth certificate issued by a State, county, municipal authority, or territory of the United States bearing an official seal

4.Native American tribal document

5.U.S. Citizen ID Card (Form I-197)

6.Identification Card for Use of Resident Citizen in the United States (Form I-179)

7.Employment authorization document issued by the Department of Homeland Security

Examples of many of these documents appear in Part 13 of the Handbook for Employers (M-274).

Refer to the instructions for more information about acceptable receipts.

Form I-9 07/17/17 N

Page 3 of 3

Form W-9	Request for Taxpayer	Give Form to the
(Rev. November 2017)	Identification Number and Certification	requester. Do not
Department of the Treasury	▶ Go to www.irs.gov/FormW9 for instructions and the latest information.	send to the IRS.
Internal Revenue Service

1Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.

2Business name/disregarded entity name, if different from above

3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of the

4 Exemptions (codes apply only to

page

following seven boxes.

certain entities, not individuals; see

instructions on page 3):

Individual/sole proprietor or

C Corporation

S Corporation

Partnership

Trust/estate

type.orPrint InstructionsSpecific

single-member LLC

Exempt payee code (if any)

Limited liability company. Enter the tax classification (C=C corporation, S=S corporation, P=Partnership) ▶

Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check

Exemption from FATCA reporting

LLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC is

code (if any)

another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC that

is disregarded from the owner should check the appropriate box for the tax classification of its owner.

Other (see instructions) ▶

(Applies to accounts maintained outside the U.S.)

5 Address (number, street, and apt. or suite no.) See instructions.

Requester’s name and address (optional)

See

6 City, state, and ZIP code

7 List account number(s) here (optional)

Part

Taxpayer Identification Number (TIN)

Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoid

Social security number

backup withholding. For individuals, this is generally your social security number (SSN). However, for a

–

resident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For other

entities, it is your employer identification number (EIN). If you do not have a number, see How to get a

TIN, later.

Note: If the account is in more than one name, see the instructions for line 1. Also see What Name and

Employer identification number

Number To Give the Requester for guidelines on whose number to enter.

–

Part II Certification

Under penalties of perjury, I certify that:

1.The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and

2.I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I am no longer subject to backup withholding; and

3.I am a U.S. citizen or other U.S. person (defined below); and

4.The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.

Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, payments other than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.

Sign	Signature of
Here	U.S. person ▶	Date ▶

	General Instructions	• Form 1099-DIV (dividends, including those from stocks or mutual

	Section references are to the Internal Revenue Code unless otherwise	funds)
		• Form 1099-MISC (various types of income, prizes, awards, or gross
	noted.
		proceeds)
	Future developments. For the latest information about developments
		• Form 1099-B (stock or mutual fund sales and certain other
	related to Form W-9 and its instructions, such as legislation enacted
		transactions by brokers)
	after they were published, go to www.irs.gov/FormW9.
		• Form 1099-S (proceeds from real estate transactions)
	Purpose of Form
		• Form 1099-K (merchant card and third party network transactions)
	An individual or entity (Form W-9 requester) who is required to file an	• Form 1098 (home mortgage interest), 1098-E (student loan interest),
		1098-T (tuition)
	information return with the IRS must obtain your correct taxpayer
		• Form 1099-C (canceled debt)
	identification number (TIN) which may be your social security number
	(SSN), individual taxpayer identification number (ITIN), adoption	• Form 1099-A (acquisition or abandonment of secured property)
	taxpayer identification number (ATIN), or employer identification number	Use Form W-9 only if you are a U.S. person (including a resident
	(EIN), to report on an information return the amount paid to you, or other
		alien), to provide your correct TIN.
	amount reportable on an information return. Examples of information
		If you do not return Form W-9 to the requester with a TIN, you might
	returns include, but are not limited to, the following.
	• Form 1099-INT (interest earned or paid)	be subject to backup withholding. See What is backup withholding,
		later.

Cat. No. 10231X

Form W-9 (Rev. 11-2017)

Page 2

By signing the filled-out form, you:

1.Certify that the TIN you are giving is correct (or you are waiting for a number to be issued),

2.Certify that you are not subject to backup withholding, or

3.Claim exemption from backup withholding if you are a U.S. exempt payee. If applicable, you are also certifying that as a U.S. person, your allocable share of any partnership income from a U.S. trade or business is not subject to the withholding tax on foreign partners' share of effectively connected income, and

4.Certify that FATCA code(s) entered on this form (if any) indicating that you are exempt from the FATCA reporting, is correct. See What is FATCA reporting, later, for further information.

Note: If you are a U.S. person and a requester gives you a form other than Form W-9 to request your TIN, you must use the requester’s form if it is substantially similar to this Form W-9.

Definition of a U.S. person. For federal tax purposes, you are considered a U.S. person if you are:

•An individual who is a U.S. citizen or U.S. resident alien;

•A partnership, corporation, company, or association created or organized in the United States or under the laws of the United States;

•An estate (other than a foreign estate); or

•A domestic trust (as defined in Regulations section 301.7701-7).

Special rules for partnerships. Partnerships that conduct a trade or business in the United States are generally required to pay a withholding tax under section 1446 on any foreign partners’ share of effectively connected taxable income from such business. Further, in certain cases where a Form W-9 has not been received, the rules under section 1446 require a partnership to presume that a partner is a foreign person, and pay the section 1446 withholding tax. Therefore, if you are a U.S. person that is a partner in a partnership conducting a trade or business in the United States, provide Form W-9 to the partnership to establish your U.S. status and avoid section 1446 withholding on your share of partnership income.

In the cases below, the following person must give Form W-9 to the partnership for purposes of establishing its U.S. status and avoiding withholding on its allocable share of net income from the partnership conducting a trade or business in the United States.

•In the case of a disregarded entity with a U.S. owner, the U.S. owner of the disregarded entity and not the entity;

•In the case of a grantor trust with a U.S. grantor or other U.S. owner, generally, the U.S. grantor or other U.S. owner of the grantor trust and not the trust; and

•In the case of a U.S. trust (other than a grantor trust), the U.S. trust (other than a grantor trust) and not the beneficiaries of the trust.

Foreign person. If you are a foreign person or the U.S. branch of a foreign bank that has elected to be treated as a U.S. person, do not use Form W-9. Instead, use the appropriate Form W-8 or Form 8233 (see Pub. 515, Withholding of Tax on Nonresident Aliens and Foreign Entities).

Nonresident alien who becomes a resident alien. Generally, only a nonresident alien individual may use the terms of a tax treaty to reduce or eliminate U.S. tax on certain types of income. However, most tax treaties contain a provision known as a “saving clause.” Exceptions specified in the saving clause may permit an exemption from tax to continue for certain types of income even after the payee has otherwise become a U.S. resident alien for tax purposes.

If you are a U.S. resident alien who is relying on an exception contained in the saving clause of a tax treaty to claim an exemption from U.S. tax on certain types of income, you must attach a statement to Form W-9 that specifies the following five items.

1.The treaty country. Generally, this must be the same treaty under which you claimed exemption from tax as a nonresident alien.

2.The treaty article addressing the income.

3.The article number (or location) in the tax treaty that contains the saving clause and its exceptions.

4.The type and amount of income that qualifies for the exemption from tax.

5.Sufficient facts to justify the exemption from tax under the terms of the treaty article.

Example. Article 20 of the U.S.-China income tax treaty allows an exemption from tax for scholarship income received by a Chinese student temporarily present in the United States. Under U.S. law, this student will become a resident alien for tax purposes if his or her stay in the United States exceeds 5 calendar years. However, paragraph 2 of the first Protocol to the U.S.-China treaty (dated April 30, 1984) allows the provisions of Article 20 to continue to apply even after the Chinese student becomes a resident alien of the United States. A Chinese student who qualifies for this exception (under paragraph 2 of the first protocol) and is relying on this exception to claim an exemption from tax on his or her scholarship or fellowship income would attach to Form W-9 a statement that includes the information described above to support that exemption.

If you are a nonresident alien or a foreign entity, give the requester the appropriate completed Form W-8 or Form 8233.

Backup Withholding

What is backup withholding? Persons making certain payments to you must under certain conditions withhold and pay to the IRS 28% of such payments. This is called “backup withholding.” Payments that may be subject to backup withholding include interest, tax-exempt interest, dividends, broker and barter exchange transactions, rents, royalties, nonemployee pay, payments made in settlement of payment card and third party network transactions, and certain payments from fishing boat operators. Real estate transactions are not subject to backup withholding.

You will not be subject to backup withholding on payments you receive if you give the requester your correct TIN, make the proper certifications, and report all your taxable interest and dividends on your tax return.

Payments you receive will be subject to backup withholding if:

1.You do not furnish your TIN to the requester,

2.You do not certify your TIN when required (see the instructions for Part II for details),

3.The IRS tells the requester that you furnished an incorrect TIN,

4.The IRS tells you that you are subject to backup withholding

because you did not report all your interest and dividends on your tax return (for reportable interest and dividends only), or

5.You do not certify to the requester that you are not subject to backup withholding under 4 above (for reportable interest and dividend accounts opened after 1983 only).

Certain payees and payments are exempt from backup withholding. See Exempt payee code, later, and the separate Instructions for the Requester of Form W-9 for more information.

Also see Special rules for partnerships, earlier.

What is FATCA Reporting?

The Foreign Account Tax Compliance Act (FATCA) requires a participating foreign financial institution to report all United States account holders that are specified United States persons. Certain payees are exempt from FATCA reporting. See Exemption from FATCA reporting code, later, and the Instructions for the Requester of Form W-9 for more information.

Updating Your Information

You must provide updated information to any person to whom you claimed to be an exempt payee if you are no longer an exempt payee and anticipate receiving reportable payments in the future from this person. For example, you may need to provide updated information if you are a C corporation that elects to be an S corporation, or if you no longer are tax exempt. In addition, you must furnish a new Form W-9 if the name or TIN changes for the account; for example, if the grantor of a grantor trust dies.

Penalties

Failure to furnish TIN. If you fail to furnish your correct TIN to a requester, you are subject to a penalty of $50 for each such failure unless your failure is due to reasonable cause and not to willful neglect.

Civil penalty for false information with respect to withholding. If you make a false statement with no reasonable basis that results in no backup withholding, you are subject to a $500 penalty.

Form W-9 (Rev. 11-2017)

Page 3

Criminal penalty for falsifying information. Willfully falsifying certifications or affirmations may subject you to criminal penalties including fines and/or imprisonment.

Misuse of TINs. If the requester discloses or uses TINs in violation of federal law, the requester may be subject to civil and criminal penalties.

Specific Instructions

Line 1

You must enter one of the following on this line; do not leave this line blank. The name should match the name on your tax return.

If this Form W-9 is for a joint account (other than an account maintained by a foreign financial institution (FFI)), list first, and then circle, the name of the person or entity whose number you entered in Part I of Form W-9. If you are providing Form W-9 to an FFI to document a joint account, each holder of the account that is a U.S. person must provide a Form W-9.

a.Individual. Generally, enter the name shown on your tax return. If you have changed your last name without informing the Social Security Administration (SSA) of the name change, enter your first name, the last name as shown on your social security card, and your new last name.

Note: ITIN applicant: Enter your individual name as it was entered on your Form W-7 application, line 1a. This should also be the same as the name you entered on the Form 1040/1040A/1040EZ you filed with your application.

b.Sole proprietor or single-member LLC. Enter your individual name as shown on your 1040/1040A/1040EZ on line 1. You may enter your business, trade, or “doing business as” (DBA) name on line 2.

c.Partnership, LLC that is not a single-member LLC, C corporation, or S corporation. Enter the entity's name as shown on the entity's tax return on line 1 and any business, trade, or DBA name on line 2.

d.Other entities. Enter your name as shown on required U.S. federal tax documents on line 1. This name should match the name shown on the charter or other legal document creating the entity. You may enter any business, trade, or DBA name on line 2.

e.Disregarded entity. For U.S. federal tax purposes, an entity that is disregarded as an entity separate from its owner is treated as a “disregarded entity.” See Regulations section 301.7701-2(c)(2)(iii). Enter the owner's name on line 1. The name of the entity entered on line 1 should never be a disregarded entity. The name on line 1 should be the name shown on the income tax return on which the income should be reported. For example, if a foreign LLC that is treated as a disregarded entity for U.S. federal tax purposes has a single owner that is a U.S. person, the U.S. owner's name is required to be provided on line 1. If the direct owner of the entity is also a disregarded entity, enter the first owner that is not disregarded for federal tax purposes. Enter the disregarded entity's name on line 2, “Business name/disregarded entity name.” If the owner of the disregarded entity is a foreign person, the owner must complete an appropriate Form W-8 instead of a Form W-9. This is the case even if the foreign person has a U.S. TIN.

Line 2

If you have a business name, trade name, DBA name, or disregarded entity name, you may enter it on line 2.

Line 3

Check the appropriate box on line 3 for the U.S. federal tax classification of the person whose name is entered on line 1. Check only one box on line 3.

IF the entity/person on line 1 is		THEN check the box for . . .
a(n) . . .

•	Corporation	Corporation
•	Individual	Individual/sole proprietor or single-
•	Sole proprietorship, or	member LLC
•	Single-member limited liability
company (LLC) owned by an
individual and disregarded for U.S.
federal tax purposes.

•	LLC treated as a partnership for	Limited liability company and enter
U.S. federal tax purposes,		the appropriate tax classification.
•	LLC that has filed Form 8832 or	(P= Partnership; C= C corporation;
2553 to be taxed as a corporation,		or S= S corporation)
or
•	LLC that is disregarded as an
entity separate from its owner but
the owner is another LLC that is
not disregarded for U.S. federal tax
purposes.

•	Partnership	Partnership

•	Trust/estate	Trust/estate

Line 4, Exemptions

If you are exempt from backup withholding and/or FATCA reporting, enter in the appropriate space on line 4 any code(s) that may apply to you.

Exempt payee code.

•Generally, individuals (including sole proprietors) are not exempt from backup withholding.

•Except as provided below, corporations are exempt from backup withholding for certain payments, including interest and dividends.

•Corporations are not exempt from backup withholding for payments made in settlement of payment card or third party network transactions.

•Corporations are not exempt from backup withholding with respect to attorneys’ fees or gross proceeds paid to attorneys, and corporations that provide medical or health care services are not exempt with respect to payments reportable on Form 1099-MISC.

The following codes identify payees that are exempt from backup withholding. Enter the appropriate code in the space in line 4.

1—An organization exempt from tax under section 501(a), any IRA, or a custodial account under section 403(b)(7) if the account satisfies the requirements of section 401(f)(2)

2—The United States or any of its agencies or instrumentalities

3—A state, the District of Columbia, a U.S. commonwealth or possession, or any of their political subdivisions or instrumentalities

4—A foreign government or any of its political subdivisions, agencies, or instrumentalities

5—A corporation

6—A dealer in securities or commodities required to register in the United States, the District of Columbia, or a U.S. commonwealth or possession

7—A futures commission merchant registered with the Commodity Futures Trading Commission

8—A real estate investment trust

9—An entity registered at all times during the tax year under the Investment Company Act of 1940

10—A common trust fund operated by a bank under section 584(a) 11—A financial institution

12—A middleman known in the investment community as a nominee or custodian

13—A trust exempt from tax under section 664 or described in section 4947

How to Edit Independent Contractor Application Online for Free

This PDF editor was created with the purpose of making it as simple and intuitive as it can be. These steps can certainly make filling in the renewals quick and easy.

Step 1: The first thing would be to press the orange "Get Form Now" button.

Step 2: At this point, you can alter the renewals. Our multifunctional toolbar permits you to add, eliminate, modify, highlight, and perform other commands to the content material and areas within the form.

In order to complete the form, enter the details the platform will request you to for each of the following sections:

Within the field City, State, Zip, Phone, Fax, Email, Type of Entity eg individual, Description of Primary Business, SIC if business, SSN if individual EIN if business, ProductsServices Offered check all, Consulting, Professional, Other, and CONTRACTING REQUEST write down the details which the application requests you to do.

Outline the crucial information in the segment.

The PREVIOUS POSITIONS Please begin, Company Phone Contact, Address, Employment Dates, Pay or Salary, Reason for leaving, Position Duties, From, Start, Final, Company Phone Contact, Address, Employment Dates, Pay or Salary, and Reason for leaving area will be the place to insert the rights and obligations of either side.

Finalize by reviewing the following sections and filling them out accordingly: Company Phone Contact, Address, Employment Dates, Pay or Salary, Reason for leaving, Position Duties, From, Start, Final, EXISTING CONTRACTUAL RELATIONSHIPS, Company, Address, Obligations, Industry Type, and Phone.

Step 3: Press "Done". You can now upload the PDF document.

Step 4: In order to prevent any type of troubles down the road, you should prepare at the very least a few duplicates of the document.

Signature of Preparer or Translator

Today's Date (mm/dd/yyyy)

Last Name (Family Name)

First Name (Given Name)

Address (Street Number and Name)

City or Town