Form Rts-6061 - Independent Contractor Analysis printable pdf download

RTS-6061

Independent Contractor Analysis

R. 01/13

Rule 73B-10.037

Florida Administrative Code

Information on this form is provided by:

Employing Unit/Business

Worker

Attach copies of any supporting documents. For example: contract, agreements, employment applications, prior IRS or

state agency rulings on worker’s job class.

Complete a separate form for each job title/class.

Employing unit/business: Answer all questions in Sections I, II, III, IV, and V.

Worker: Answer all questions, except Section IV.

Note: If you do not know an answer, write ‘do not know’ or NA, if not applicable.

Section I

1. Name, address, telephone and fax number(s) of the employing unit/business: _______________________________

____________________________________________________________________________________________________

2. Type of work done by the employing unit/business: ______________________________________________________

____________________________________________________________________________________________________

3. Name of the worker: _________________________________________________________________________________

4. Worker’s social security number: ______________________________________________________________________

5. Worker’s federal employer identification number (if applicable): ____________________________________________

6. Worker’s job title or class: _____________________________________________________________________________

7. If worker’s duties were not part of the employing unit’s regular business, how did they differ? _________________

____________________________________________________________________________________________________

8. Dates worker performed services for the employing unit/business: _________________________________________

9. Was 1099-MISC or W-2 given to the worker?

Yes

If yes, attach copy.

• If worker was given both 1099-MISC and W-2, explain what changed and give dates for 1099-MISC vs

W-2 duties: ___________________________________________________________________________________

______________________________________________________________________________________________

10. Briefly describe the worker’s job (add additional page if needed): __________________________________________

____________________________________________________________________________________________________

11. If the worker is still performing services, describe the working arrangements through the current date: _________

____________________________________________________________________________________________________

Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the

administration of Florida’s taxes. SSNs obtained for tax administration purposes are confidential under sections 213.053

and 119.071, Florida Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized

under state and federal law. Visit our Internet site at and select “Privacy Notice” for more

information regarding the state and federal law governing the collection, use, or release of SSNs, including authorized

exceptions.

Form Rts-6061 - Independent Contractor Analysis