Form 68-0192 - Questionnaire For Determining Status Of Worker

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Questionnaire for Determining Status of Worker
68-0192 (04-12)
Unemployment Insurance Tax Bureau
1000 E Grand Ave
Des Moines IA 50319-0209
Phone: 888-848-7442 option #3 then option #7
Under the Iowa Employment Security Law, every person performing services for pay is presumed to be an
employee, unless the department is satisfied this person is self-employed or an independent contractor.
The word FIRM, as used in this form, includes any type of business organization.
A SIGNATURE IS REQUIRED ON THE BOTTOM OF PAGE 5. All parties must answer questions on pages 1
through 4. If the position involves sales, also complete the bottom of page 4 and all of page 5. Attach
supplemental sheets for those questions which require more space.
Attach copies of written agreements, instruction manuals, rules and policies to be followed. Include copies of
invoices, memos, W-2 and 1099 forms. Provide us with any documentation you feel is important. In addition,
please inform us of current litigation concerning the worker.
The department's ruling on this matter will apply to the worker listed below and to any other worker in the
same class. If you want a ruling on more than one class of workers, you should submit a separate
questionnaire form, 68-0192, for each class.
Firm or individual for whom worker performed services:
Address 1:
Address 2:
Zip/Postal Code:
Worker that performed services:
Address 1:
Address 2:
Zip/Postal Code:
Type of Organization:
Sole Proprietor
Professional Corporation (PC)
Religious Organization
Limited Liability Company (LLC)
Limited Liability Partnership (LLP)
Other (Specify)
*Attach a list of all workers to whom this questionnaire applies. List their names, home addresses,
Social Security Numbers and periods of service.
Equal Opportunity Employer/Program
Auxiliary aids & services are available upon request to individuals with disabilities.
Page 1
For deaf and hard of hearing, use Relay 711.


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