University Of Rochester Independent Contractor Determination And Certification Form Ic (7/1/13) (Page 3 of 3) in pdf

PART II Independent Contractor Determination – to be completed by individual performing service:

Independent Contractor Determination: By signing below, I warrant and affirm that the information provided in Part I is true, complete and correct. I

agree to personally, indemnify and hold the University of Rochester harmless from any claim, damages or liabilities resulting directly or indirectly from

UNIVERSITY OF ROCHESTER

reliance thereon. I understand that I qualify

or do not qualify

(You must check one, and only one) as an Independent Contractor and that I am

responsible for any taxes resulting from this engagement, and certify that I pay my own federal, state or local income, social security, and other taxes in

INDEPENDENT CONTRACTOR DETERMINATION AND CERTIFICATION

accordance with tax payment requirements. I acknowledge that, as an independent contractor, I am not eligible for workers compensation, unemployment

FORM IC (7/1/13)

compensation or other University employee benefits. I understand that the University will issue a Form 1099-MISC to independent contractors who receive

over ________ 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.

Name (print): ________________________________________________________ Title: ________________________________

Signature: ___________________________________________________________ Date: ________________________________

Return this signed form to the University department/unit that engaged you to perform services. Do NOT begin work until you have received a signed

copy of this form from the University.

If you qualify as an independent contractor, most engagements require you to obtain a Purchase Order and enter into a Professional Services Agreement

from the University prior to beginning work. Do not begin work until you have a Purchase Order and Professional Services Agreement or have

verified that you are not required to obtain either. Failure to follow this instruction may result in nonpayment for services. If you do not qualify as an

independent contractor you must go through the employment hiring and payroll process before performing services.

Please provide original signed form to the University department / unit representative engaging your services.

PART III -- For Official Use Only --TWO SIGNATURES ARE REQUIRED FOR PAYMENT IF INDEPENDENT CONTRACTOR

THIS PART TO BE COMPLETED BY UNIVERSITY DEPARTMENT/UNIT REPRESENTATIVE:

The University employee signing below warrants: that he or she has reviewed the information provided on this form as it pertains to services

provided; that the information is true to the best of the signer’s knowledge, and; the individual’s representations regarding the services to be

performed and concomitant compensation to be paid are correct. I further acknowledge that the Department will follow all required University

purchasing approvals, including the entering into of a Purchase Order and Professional Services Agreement, where required.

The signer below should be the University Employee most familiar with the independent contractors operations

__________________________________________________

________________________________________________ Date: __________

(Print Name)

(Sign Name)

I have reviewed University Personnel Policy 122 and the information provided on the reverse side of this form as it pertains to services provided. Based

upon my review, and/or other knowledge that I may possess, I have determined that the reverse side of this form is complete and the Individual qualifies

or does not qualify

(You must check one and only one) as an Independent Contractor as that term is defined by the Internal Revenue Code.

The signer below should be the University Employee with the authority to request payment for the independent contractor (i.e., approve a Disbursement

Voucher or Requisition)

__________________________________________________

________________________________________________ Date: __________

(Print Name)

(Sign Name)

Authorized College/Division Representative (if applicable) _____________________________________________Date__________________

(Sign Name)

Please submit this original form to Purchasing Box 278901 along with the 312 requisition and executed PSA

or to Accounts Payable as supporting documentation with the Request for Payment F-4 form.

University Of Rochester Independent Contractor Determination And Certification Form Ic (7/1/13) Page 3

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