Form Ss 8 North Carolina Office Of The State Controller (Page 3 of 3) in pdf

Form Ss 8 North Carolina Office Of The State Controller Page 3

OSC Form 319

Page 3

(Rev March 2002)

Does the firm carry worker’s compensation insurance on the worker?

Yes

10 What economic loss or financial risk, if any, can the worker incur beyond the normal loss of salary (e.g., loss

or damage of equipment, material, etc.)?

PART III

Relationship of the Worker and Agency

1 List the benefits available to the worker (e.g., paid vacations, sick pay, pensions, bonuses).

2 Can the relationship be terminated by either party without incurring liability or penalty?

Yes

If No, explain your answer.

3 Does the worker perform similar services for others?

Yes

If “Yes”, is the worker required to get approval from the firm?

Yes

4 Describe any agreements prohibiting competition between the worker and the firm while the worker is

performing services or during any later period.

Attach any available documentation.

5 Is the worker a member of a union?

Yes

6 What type of advertising, if any, does the worker do (e.g., a business listing in a directory, business

cards, etc.)?

Provide copies, if applicable.

If the worker assembles or processes a product at home, who provides the materials and instructions

or pattern?

What does the worker do with the finished product (e.g., return it to the agency, provide it to another,

or sell It)?

9 How does the agency represent the worker to its customers (e.g., employee, partner, representative, or

contractor)?

If the worker no longer performs services for the firm, how did the relationship end?

PART IV

Signature

Under penalties of perjury, 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.

Signature

Title

Date

(Type or print name below)

Form Ss 8 North Carolina Office Of The State Controller Page 3