Form 68-0192 - Questionnaire For Determining Status Of Workers printable pdf download

IOWA WORKFORCE DEVELOPMENT

TAX BUREAU, UIS DIVISION

DOCUMENT ID NUMBER

ACCOUNT NUMBER/LOCATION or SSN

DOCUMENT CONTROL

68-0192

DATE

1000 East Grand Avenue

Des Moines, Iowa 50319-0209

DESCRIPTION

Questionnaire for Determining

DESCRIPTION (CONTINUED)

Status of Workers

FOR ADMINISRATIVE

OFFICE USE ONLY

68-0192 (7-03)

Under the Iowa Employment Security Law, it is presumed that every person performing services for pay under a contract of hire or

service, expressed or implied, made either directly with you or by someone in your employ, is your employee, unless and until you

satisfy the department that such an individual is a self-employed excluded contractor as defined by section 96.19-18f of the Iowa

Employment Security Law.

THE FIRM MUST ESTABLISH:

1. That such individual has been and will continue to be free from control or direction over the performance of the worker's services

both under the worker's contract and in fact....

2. That such services have been performed in an independently established trade, business, or profession in which the individual is

customarily engaged.

INSTRUCTIONS

A.Sales personnel should give complete answers to all questions: If the position is other than sales, give complete answers to ques

tions 1 through 29. Attach supplemental sheets for those questions which require more space than is allotted in the questionnaire.

B.Also, attach a copy of any written agreement, manual of instructions, statement of rules or policies required to be followed, and any

rulings made by other governmental agencies with respect to whether the worker in question is an employee or independent

contractor.

C.The department's ruling on this matter will apply to the individual identified below and to those included on an attached listing. If a

ruling is desired on more than one class of workers or agents, a separate questionnaire, 68-0192, should be completed for each

class.

D.The word FIRM, as used in this form, includes an individual, a corporation, a partnership, an association, or any other form or type

of business organization.

_______________________________________________________________________________________________________________________________________________________

NAME OF FIRM

NAME OF WORKER

__________________________________________________________________________________________________________________________________________________________

ADDRESS OF FIRM

HOME ADDRESS OF WORKER

_____________________________________________________________________________________________________________________________________________________________

NATURE OF FIRM'S BUSINESS

(WORKER'S) SOCIAL SECURITY NUMBER, IF ANY

SERVICES PERFORMED FOR THIS FIRM

_______________________________________________________________________________________________________________________________________________________

FORM OF ORGANIZATION .... (CHECK ONE)

INDIVIDUAL

PARTNERSHIP

CORPORATION

OTHER (SPECIFY)

___________________________________________________________________________________________________________________________

_______________

_____________

NATURE OF SERVICES PERFORMED BY THE WORKER

DATES WHEN SERVICES WERE PERFORMED

FROM

___________________________________________________________________________________________________________________________

ATTACH A LISTING OF ALL OTHER WORKERS OR AGENTS TO WHOM THIS QUESTIONNAIRE APPLIES, INDICATING THE NAMES, HOME ADDRESSES,

SOCIAL SECURITY NUMBERS AND PERIODS OF SERVICE.

YES

1.Is there any written agreement concerning the employment? ............................................................................................

IF YES, a copy must be furnished to this department. IF NO, explain the verbal agreement that exists.