OMB. No. 1545-0004
Determination of Worker Status for Purposes
For IRS Use Only:
of Federal Employment Taxes and
(Rev. August 2011)
Income Tax Withholding
Earliest Receipt Date:
Department of the Treasury
Internal Revenue Service
Name of firm (or person) for whom the worker performed services
Firm’s mailing address (include street address, apt. or suite no., city, state, and ZIP code)
Worker’s mailing address (include street address, apt. or suite no., city, state, and ZIP code)
Firm's email address
Worker's daytime telephone number
Worker's email address
Firm's fax number
Worker's alternate telephone number
Worker's fax number
Firm's telephone number (include area code)
Firm’s employer identification number
Worker’s social security number
Worker’s employer identification number (if any)
Note. If the worker is paid for these services by a firm other than the one listed on this form, enter the name, address, and employer identification
number of the payer.
Disclosure of Information
The information provided on Form SS-8 may be disclosed to the firm, worker, or payer named above to assist the IRS in the determination process.
For example, if you are a worker, we may disclose the information you provide on Form SS-8 to the firm or payer named above. The information can
only be disclosed to assist with the determination process. If you provide incomplete information, we may not be able to process your request. See
Privacy Act and Paperwork Reduction Act Notice on page 6 for more information. If you do not want this information disclosed to other parties, do
not file Form SS-8.
Parts I–V. All filers of Form SS-8 must complete all questions in Parts I–IV. Part V must be completed if the worker provides a service directly to
customers or is a salesperson. If you cannot answer a question, enter “Unknown” or “Does not apply.” If you need more space for a question, attach
another sheet with the part and question number clearly identified. Write your firm's name (or workers' name) and employer identification number (or
social security number) at the top of each additional sheet attached to this form.
This form is being completed by:
Worker; for services performed
Explain your reason(s) for filing this form (for example, you received a bill from the IRS, you believe you erroneously received a Form 1099 or
Form W-2, you are unable to get worker’s compensation benefits, or you were audited or are being audited by the IRS).
Total number of workers who performed or are performing the same or similar services:
How did the worker obtain the job?
Attach copies of all supporting documentation (for example, contracts, invoices, memos, Forms W-2 or Forms 1099-MISC issued or received, IRS
closing agreements or IRS rulings). In addition, please inform us of any current or past litigation concerning the worker’s status. If no income reporting forms
(Form 1099-MISC or W-2) were furnished to the worker, enter the amount of income earned for the year(s) at issue
If both Form W-2 and Form 1099-MISC were issued or received, explain why.
Describe the firm’s business.
For Privacy Act and Paperwork Reduction Act Notice, see page 6.
Cat. No. 16106T