Independent Contractor Form (Page 2 of 2) in pdf

PART II -- To be read and signed by Individual providing the service -- SIGNATURE REQUIRED FOR PAYMENT

By signing below, I warrant and affirm that the information provided herein is true, complete and correct. I agree to personally indemnify

and hold the University of Hartford harmless from any claim, damages or liabilities resulting directly or indirectly from reliance thereon. I

understand that I qualify

or do not qualify

(You must check one, and only one) as an Independent Contractor and that I am

responsible for any taxes resulting from this engagement.

Name (print)________________________________________________________ Title________________________________

Signature___________________________________________________________ Date_______________________________

Return this signed form with a completed IRS W-9 form and proof of liability insurance coverage to the University department/unit that

engaged you to perform services. Do NOT begin work until you have received a signed copy of this form and a Purchase Order

number from the University.

If you qualify as an independent contractor, all engagements require you to obtain a Purchase Order from the University prior to

beginning work. Do not begin work until you have a purchase order. Failure to follow these instructions may result in nonpayment

for services. This form combined with the University Purchase Order (and Contractual Agreement, if applicable) constitutes the entire

agreement between you and the University of Hartford. Independent Contractors are required to invoice the University of Hartford for

services rendered in accordance with the terms of the Purchase Order (and Contractual Agreement, if applicable). All invoices must

reference the applicable Purchase Order number.

If you do not qualify as an independent contractor you must go through the payroll process before performing services.

***FOR HRD COMPLETION ONLY***

PART III -- For Official Use Only

Section I – Verification of employment at the University – THE UNIVERSITY DEPARTMENT/UNIT REPRESENTATIVE MUST

ENSURE THE COMPLETION OF THIS SECTION BY AN HRD REPRESENTATIVE.

The above named individual is

or is not

(You must check one, and only one) a current employee of the University of

Hartford.

If a former employee, the last date of employment was ________________________.

_____________________________________

_____________________________

______________

Signature

Title

Date

Section II - TWO SIGNATURES ARE REQUIRED FOR PAYMENT. THIS PART TO BE COMPLETED BY A UNIVERSITY

DEPARTMENT/UNIT REPRESENTATIVE:

The University employee signing below warrants: that he or she has reviewed the information provided on this form; that the

information is true to best of the signer’s knowledge, and; the individual’s representations regarding the services to be

performed and concomitant compensation to be paid are correct.

The signer below should be the University Employee most familiar with the independent contractor’s operations.

______________________________________________________________________________________

(Print Name)

_______________________________________________________________________________________

(Signature)

I have reviewed the Independent Contractor Policy and the information provided on this form. Based upon my review, and/or other

knowledge that I may possess, I have determined that this form is complete and the Individual named in Part I qualifies

or does not

qualify

(You must check one and only one) as an Independent Contractor as that term is defined by the Internal Revenue Code.

The signer below should be the Supervisor of the University Employee who has reviewed the information and signed above. This person

should also have the authority to approve payment for the independent contractor in accordance with the existing Purchasing / Accounts

Payable approval process.

______________________________________________________________________Date______________

(Print Name)

______________________________________________________________________ Date _____________

(Signature)

*Once this form is properly completed please forward to the Procurement Department for processing.

We will send you the vendor ID # for you to use when creating the Purchase Requisition.

Rev 8-26-15

Independent Contractor Form Page 2

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