Form Ss-8 - Determination Of Worker Status For Purposes Of Federal Employment Taxes And Income Tax Withholding Page 4

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Form SS-8 (Rev. 5-2014)
Page
Part V
For Service Providers or Salespersons. Complete this part if the worker provided a service directly to
customers or is a salesperson.
1
What are the worker’s responsibilities in soliciting new customers?
2
Who provides the worker with leads to prospective customers?
3
Describe any reporting requirements pertaining to the leads.
4
What terms and conditions of sale, if any, are required by the firm?
5
Are orders submitted to and subject to approval by the firm? .
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Yes
No
6
Who determines the worker’s territory?
7
Did the worker pay for the privilege of serving customers on the route or in the territory? .
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Yes
No
If “Yes,” whom did the worker pay?
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If “Yes,” how much did the worker pay?
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8
Where does the worker sell the product (for example, in a home, retail establishment)?
List the product and/or services distributed by the worker (for example, meat, vegetables, fruit, bakery products, beverages, or laundry or dry
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cleaning services). If more than one type of product and/or service is distributed, specify the principal one.
10
Does the worker sell life insurance full time? .
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Yes
No
11
Does the worker sell other types of insurance for the firm? .
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Yes
No
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If “Yes,” enter the percentage of the worker’s total working time spent in selling other types of insurance .
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12
If the worker solicits orders from wholesalers, retailers, contractors, or operators of hotels, restaurants, or other similar
establishments, enter the percentage of the worker’s time spent in the solicitation .
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%
13
Is the merchandise purchased by the customers for resale or use in their business operations? .
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Yes
No
Describe the merchandise and state whether it is equipment installed on the customers’ premises.
Under penalties of perjury, I declare that I have examined this request, including accompanying documents, and to the best of my knowledge and belief, the
facts presented are true, correct, and complete.
Sign
Title
Date
Here
Type or print name below signature.
SS-8
Form
(Rev. 5-2014)

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