working relationship form - esf...working relationship form . campus address: date: name of...
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NYS
WORKING RELATIONSHIP FORM
Campus Address
Date
Name of Independent Contractor
Address
We have received notification from ----------------------- Project Director that you have or will be rendering services to hi sher research project as an independent contractor As an independent contractor no employeeshyemployer relationship exists between you and the State University of New York
We would like to take this opportunity to clarify your slatus with the State University of New York If you feel that we have made a mjstake in your classification you must notify us within ten (10) working days from the date of this letter As an independent contractor you are
bull not eligible to file for or to collect unemployment benefits bull not eligible for workers compensation coverage bull solely responsible for complying with all federal state and local requirements regarding reporting and paying taxes bull required to assign all right title and interest in the data or material you produce as a result of project activities to the State
University of New York and are prohibited from publishing permitting to be published or distributing any information concerning the results or conclusions of the data or material you produce during or towards project activities They are considered works for hire and are the property of the State University of New York
bull able to retain ownership of intellectual property included in deliverables to the extent that you have independently developed the intellectual property without State University of New York financial support With respect to such property you agree to grant to the State University of New York a royalty free nonexclusive license to use such intellectual property for purposes consistent with the State University ofNew Yorks obligations under the grant or contract that funds this project
bull Independent of the State University of New York as defined by generally accepted auditing standards and US Government Accountability Office (GAO)s Government Auditing Standards Accordingly no relationship exists between the State University of New York ESF or any of its employees Board Members or with any other person or agency that constitutes a conflict of interest with respect to the State University of New York You agree to give the State University of New York written notice of any relationships entered into during the period of the agreement that would present a question concerning your independence as Independent Contractor
bull Are not currently or within the past two years a former SUNY employee bull Have no existing professional relationships that would present a conflict of interest between you and the State University of New
York In addition you will give the State University of New York written notice of any professional relationships entered into during the period of the agreement that would present a conflict of interest You have not had any professional relationships involving SUNY ESF or any of its affiliates in the past five years that would constitute a conflict of interest relative to this agreement
Your engagement as an independent contractor with the State University of New York may be cancelled by the State University of New York upon 30-days written notice
Please read Page 2 of this form for a description of your services and fees
If you have any questions or disagree with the information listed on this document or need any additional information concerning your status as an independent contractor please feel free to contact ___________ (Name) at _________ (Phone Number)
(Director of Business Affairs)
cc (project director)
(complete the bottom section and return the form to the campus if fees plus expenses are $2500 or more)
I certify that I have read understand and accept this document and any attachments
Signature Tax Payer ID Number Date
Description of Services
Period of Service
Fees and Expenses (Include maximum dollar amount of compensation)
Payment Schedules
Technical and Final Reporting Requirements
Other Information
G- Bulletin No233 Page 1 of2 Attachment B
EmployeeIndependent Contractor Status Determination Worksheet
Use this Attachment B in conjunction with Attachments A and C to make worker status determinations
These questions provide only a guideline for worker status determination
Highlighted answers~ strongly suggest an employeremployee relationship according to the guidelines provided by the IRS Agencies should carefully consider these factors when making their determinations
If a satisfactory determination cannot be made using these guidelines or the agency and the worker do not agree on the interpretation of the facts either the agency or the worker may request a specific IRS determination by filing IRS Form SS-8
If an agency chooses to complete Form SS-8 for an IRS Determination the form and filing instructions may be accessed via the IRS website httpwwwirsgov
Please complete the following information
Worker Name
Agency
SSN
Please respond YES or NO to each of the following questions For purposes of this worksheet the term employer means the agency for which services are performed
YES NO
1 Is the worker required to follow the employers instructions on how to complete the job or accomplish the task
2 Does the employer provide the training necessary for completion of the job
3 Are the workers services crucial to the success or continued existence of the agency
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
G- Bulletin No233 Page 2 of2 Attachment 8
Are the workers specific personal services required for successful completion of the job
Does the employer hire supervise or pay any of the workers assistants
Does the worker have a continuing relationship with the company
Does the employer set work hours
Is the worker precluded from seeking assignments with other companies middot
Is the worker required to accept assignments offered by the employer
Is the work performed on the employers premises
Does the employer direct the order or sequence of tasks to be performed
Does the employer require regular oral or written reports
Is the worker paid by the hour week or month rather than for the completion (or stage of completion) of the project
Does the employer pay business andor travel expenses
Does the employer provide equipment tools and materials
Does the worker have a significant investment in equipment or facilities that are used in performing the services
Can the worker realize a profit or suffer a loss as a result of performing the services
Does the worker work only for the employer
Are the workers services not available to the general public
Does the employer have the right to terminate the worker even if the job results are achieved
Does the worker have the right to end his or her relationship with the employer at any time without liability
E~ State University of New York
College of Environmental Science and Forestry
Office of Business Affairs
New York State Workers Compensation Law Section 57 and 220 require State Agencies to ensure PRIOR to entering into any contract (inc purchase orders) that the intended vendor has appropriate NYS workers compensation and disability insurance coverage Please note ACORD certificate of insurance forms are not acceptable documentation for proof of coverage A vendors insurance carrier must provide the vendor with copies of the correct completed New York State forms to present to the State Agency purchasing agent AND must submit these forms (annually) to the Workers Comp Board so they can be properly recorded State Agencies ore prohibited from issuing purchase orderscontracts untfl the proper forms hove been received and verified
Please provide forms for BOTH of the below coverages
A Workers Compensation coverage C-1052 or U-263 or Sl-12GSl-1052
AND
B Disability Coverage DB-1201 or DB-155
If you are exempt from providing coverage we will need to have a copy of your Certificate of Attestation of Exemption Form CE-200
For more information or questions please visit wwwwcbnygov Or contact Workers Comp (877) 632-
4996
1 Forestry Drivebull 102 Bray Hallbull Syracuse New York 13210 bull wwwesfedu
Description of Services
Period of Service
Fees and Expenses (Include maximum dollar amount of compensation)
Payment Schedules
Technical and Final Reporting Requirements
Other Information
G- Bulletin No233 Page 1 of2 Attachment B
EmployeeIndependent Contractor Status Determination Worksheet
Use this Attachment B in conjunction with Attachments A and C to make worker status determinations
These questions provide only a guideline for worker status determination
Highlighted answers~ strongly suggest an employeremployee relationship according to the guidelines provided by the IRS Agencies should carefully consider these factors when making their determinations
If a satisfactory determination cannot be made using these guidelines or the agency and the worker do not agree on the interpretation of the facts either the agency or the worker may request a specific IRS determination by filing IRS Form SS-8
If an agency chooses to complete Form SS-8 for an IRS Determination the form and filing instructions may be accessed via the IRS website httpwwwirsgov
Please complete the following information
Worker Name
Agency
SSN
Please respond YES or NO to each of the following questions For purposes of this worksheet the term employer means the agency for which services are performed
YES NO
1 Is the worker required to follow the employers instructions on how to complete the job or accomplish the task
2 Does the employer provide the training necessary for completion of the job
3 Are the workers services crucial to the success or continued existence of the agency
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
G- Bulletin No233 Page 2 of2 Attachment 8
Are the workers specific personal services required for successful completion of the job
Does the employer hire supervise or pay any of the workers assistants
Does the worker have a continuing relationship with the company
Does the employer set work hours
Is the worker precluded from seeking assignments with other companies middot
Is the worker required to accept assignments offered by the employer
Is the work performed on the employers premises
Does the employer direct the order or sequence of tasks to be performed
Does the employer require regular oral or written reports
Is the worker paid by the hour week or month rather than for the completion (or stage of completion) of the project
Does the employer pay business andor travel expenses
Does the employer provide equipment tools and materials
Does the worker have a significant investment in equipment or facilities that are used in performing the services
Can the worker realize a profit or suffer a loss as a result of performing the services
Does the worker work only for the employer
Are the workers services not available to the general public
Does the employer have the right to terminate the worker even if the job results are achieved
Does the worker have the right to end his or her relationship with the employer at any time without liability
E~ State University of New York
College of Environmental Science and Forestry
Office of Business Affairs
New York State Workers Compensation Law Section 57 and 220 require State Agencies to ensure PRIOR to entering into any contract (inc purchase orders) that the intended vendor has appropriate NYS workers compensation and disability insurance coverage Please note ACORD certificate of insurance forms are not acceptable documentation for proof of coverage A vendors insurance carrier must provide the vendor with copies of the correct completed New York State forms to present to the State Agency purchasing agent AND must submit these forms (annually) to the Workers Comp Board so they can be properly recorded State Agencies ore prohibited from issuing purchase orderscontracts untfl the proper forms hove been received and verified
Please provide forms for BOTH of the below coverages
A Workers Compensation coverage C-1052 or U-263 or Sl-12GSl-1052
AND
B Disability Coverage DB-1201 or DB-155
If you are exempt from providing coverage we will need to have a copy of your Certificate of Attestation of Exemption Form CE-200
For more information or questions please visit wwwwcbnygov Or contact Workers Comp (877) 632-
4996
1 Forestry Drivebull 102 Bray Hallbull Syracuse New York 13210 bull wwwesfedu
G- Bulletin No233 Page 1 of2 Attachment B
EmployeeIndependent Contractor Status Determination Worksheet
Use this Attachment B in conjunction with Attachments A and C to make worker status determinations
These questions provide only a guideline for worker status determination
Highlighted answers~ strongly suggest an employeremployee relationship according to the guidelines provided by the IRS Agencies should carefully consider these factors when making their determinations
If a satisfactory determination cannot be made using these guidelines or the agency and the worker do not agree on the interpretation of the facts either the agency or the worker may request a specific IRS determination by filing IRS Form SS-8
If an agency chooses to complete Form SS-8 for an IRS Determination the form and filing instructions may be accessed via the IRS website httpwwwirsgov
Please complete the following information
Worker Name
Agency
SSN
Please respond YES or NO to each of the following questions For purposes of this worksheet the term employer means the agency for which services are performed
YES NO
1 Is the worker required to follow the employers instructions on how to complete the job or accomplish the task
2 Does the employer provide the training necessary for completion of the job
3 Are the workers services crucial to the success or continued existence of the agency
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
G- Bulletin No233 Page 2 of2 Attachment 8
Are the workers specific personal services required for successful completion of the job
Does the employer hire supervise or pay any of the workers assistants
Does the worker have a continuing relationship with the company
Does the employer set work hours
Is the worker precluded from seeking assignments with other companies middot
Is the worker required to accept assignments offered by the employer
Is the work performed on the employers premises
Does the employer direct the order or sequence of tasks to be performed
Does the employer require regular oral or written reports
Is the worker paid by the hour week or month rather than for the completion (or stage of completion) of the project
Does the employer pay business andor travel expenses
Does the employer provide equipment tools and materials
Does the worker have a significant investment in equipment or facilities that are used in performing the services
Can the worker realize a profit or suffer a loss as a result of performing the services
Does the worker work only for the employer
Are the workers services not available to the general public
Does the employer have the right to terminate the worker even if the job results are achieved
Does the worker have the right to end his or her relationship with the employer at any time without liability
E~ State University of New York
College of Environmental Science and Forestry
Office of Business Affairs
New York State Workers Compensation Law Section 57 and 220 require State Agencies to ensure PRIOR to entering into any contract (inc purchase orders) that the intended vendor has appropriate NYS workers compensation and disability insurance coverage Please note ACORD certificate of insurance forms are not acceptable documentation for proof of coverage A vendors insurance carrier must provide the vendor with copies of the correct completed New York State forms to present to the State Agency purchasing agent AND must submit these forms (annually) to the Workers Comp Board so they can be properly recorded State Agencies ore prohibited from issuing purchase orderscontracts untfl the proper forms hove been received and verified
Please provide forms for BOTH of the below coverages
A Workers Compensation coverage C-1052 or U-263 or Sl-12GSl-1052
AND
B Disability Coverage DB-1201 or DB-155
If you are exempt from providing coverage we will need to have a copy of your Certificate of Attestation of Exemption Form CE-200
For more information or questions please visit wwwwcbnygov Or contact Workers Comp (877) 632-
4996
1 Forestry Drivebull 102 Bray Hallbull Syracuse New York 13210 bull wwwesfedu
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
G- Bulletin No233 Page 2 of2 Attachment 8
Are the workers specific personal services required for successful completion of the job
Does the employer hire supervise or pay any of the workers assistants
Does the worker have a continuing relationship with the company
Does the employer set work hours
Is the worker precluded from seeking assignments with other companies middot
Is the worker required to accept assignments offered by the employer
Is the work performed on the employers premises
Does the employer direct the order or sequence of tasks to be performed
Does the employer require regular oral or written reports
Is the worker paid by the hour week or month rather than for the completion (or stage of completion) of the project
Does the employer pay business andor travel expenses
Does the employer provide equipment tools and materials
Does the worker have a significant investment in equipment or facilities that are used in performing the services
Can the worker realize a profit or suffer a loss as a result of performing the services
Does the worker work only for the employer
Are the workers services not available to the general public
Does the employer have the right to terminate the worker even if the job results are achieved
Does the worker have the right to end his or her relationship with the employer at any time without liability
E~ State University of New York
College of Environmental Science and Forestry
Office of Business Affairs
New York State Workers Compensation Law Section 57 and 220 require State Agencies to ensure PRIOR to entering into any contract (inc purchase orders) that the intended vendor has appropriate NYS workers compensation and disability insurance coverage Please note ACORD certificate of insurance forms are not acceptable documentation for proof of coverage A vendors insurance carrier must provide the vendor with copies of the correct completed New York State forms to present to the State Agency purchasing agent AND must submit these forms (annually) to the Workers Comp Board so they can be properly recorded State Agencies ore prohibited from issuing purchase orderscontracts untfl the proper forms hove been received and verified
Please provide forms for BOTH of the below coverages
A Workers Compensation coverage C-1052 or U-263 or Sl-12GSl-1052
AND
B Disability Coverage DB-1201 or DB-155
If you are exempt from providing coverage we will need to have a copy of your Certificate of Attestation of Exemption Form CE-200
For more information or questions please visit wwwwcbnygov Or contact Workers Comp (877) 632-
4996
1 Forestry Drivebull 102 Bray Hallbull Syracuse New York 13210 bull wwwesfedu
E~ State University of New York
College of Environmental Science and Forestry
Office of Business Affairs
New York State Workers Compensation Law Section 57 and 220 require State Agencies to ensure PRIOR to entering into any contract (inc purchase orders) that the intended vendor has appropriate NYS workers compensation and disability insurance coverage Please note ACORD certificate of insurance forms are not acceptable documentation for proof of coverage A vendors insurance carrier must provide the vendor with copies of the correct completed New York State forms to present to the State Agency purchasing agent AND must submit these forms (annually) to the Workers Comp Board so they can be properly recorded State Agencies ore prohibited from issuing purchase orderscontracts untfl the proper forms hove been received and verified
Please provide forms for BOTH of the below coverages
A Workers Compensation coverage C-1052 or U-263 or Sl-12GSl-1052
AND
B Disability Coverage DB-1201 or DB-155
If you are exempt from providing coverage we will need to have a copy of your Certificate of Attestation of Exemption Form CE-200
For more information or questions please visit wwwwcbnygov Or contact Workers Comp (877) 632-
4996
1 Forestry Drivebull 102 Bray Hallbull Syracuse New York 13210 bull wwwesfedu