OMB. No. 1545-0004
Form   SS-8                     Determination of Worker Status for Purposes                                                             For IRS Use Only: 
(Rev. May 2014)                                                                                                                         Case Number:  
                                             of Federal Employment Taxes and  
Department of the Treasury                       Income Tax Withholding                                                                 Earliest Receipt Date:
Internal Revenue Service        ▶ Information about Form SS-8 and its separate instructions is at www.irs.gov/formss8. 
Name of firm (or person) for whom the worker performed services                               Worker’s name

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)

Trade name                           Firm's email address                                     Worker's daytime telephone number   Worker's email address

Firm's fax number                    Firm's website                                           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 in the separate instructions 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 worker's name) and employer identification number (or 
social security number) at the top of each additional sheet attached to this form.

Part I     General Information

1      This form is being completed by:     Firm    Worker; for services performed                                                  to                    .
                                                                                                           (beginning date)             (ending date)
2      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 workers' compensation benefits, or you were audited or are being audited by the IRS).

3      Total number of workers who performed or are performing the same or similar services:                                           .
4      How did the worker obtain the job?     Application       Bid                           Employment Agency                   Other (specify)
5      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.

6      Describe the firm’s business.

For Privacy Act and Paperwork Reduction Act Notice, see the separate instructions.                         Cat. No. 16106T              Form SS-8 (Rev. 5-2014)

Form SS-8 (Rev. 5-2014)                                                                                                         Page 2
Part I  General Information (continued)
7  If the worker received pay from more than one entity because of an event such as the sale, merger, acquisition, or reorganization of the firm for 
   whom the services are performed, provide the following: Name of the firm's previous owner:
   Previous owner's taxpayer identification number:                      Change was a:     Sale   Merger   Acquisition      Reorganization
        Other (specify)
   Description of above change:

   Date of change (MM/DD/YY):
8  Describe the work done by the worker and provide the worker’s job title.

9  Explain why you believe the worker is an employee or an independent contractor.

10 Did the worker perform services for the firm in any capacity before providing the services that are the subject of this determination request?
        Yes             No N/A
   If “Yes,” what were the dates of the prior service?
   If “Yes,” explain the differences, if any, between the current and prior service.

11 If the work is done under a written agreement between the firm and the worker, attach a copy (preferably signed by both parties). Describe the 
   terms and conditions of the work arrangement.

Part II Behavioral Control (Provide names and titles of specific individuals, if applicable.)
1  What specific training and/or instruction is the worker given by the firm?

2  How does the worker receive work assignments?

3  Who determines the methods by which the assignments are performed?
4  Who is the worker required to contact if problems or complaints arise and who is responsible for their resolution?

5  What types of reports are required from the worker? Attach examples.

6  Describe the worker’s daily routine such as his or her schedule or hours.

7  At what location(s) does the worker perform services (for example, firm’s premises, own shop or office, home, customer’s location)? Indicate 
   the appropriate percentage of time the worker spends in each location, if more than one.

8  Describe any meetings the worker is required to attend and any penalties for not attending (for example, sales meetings, monthly meetings, 
   staff meetings).
9  Is the worker required to provide the services personally?  . . .     .   . .    . . .  . .  . . . .  . .         . .    Yes No
10 If substitutes or helpers are needed, who hires them?
11 If the worker hires the substitutes or helpers, is approval required? .   . .    . . .  . .  . . . .  . .         . .    Yes No
   If “Yes,” by whom?
12 Who pays the substitutes or helpers?
13 Is the worker reimbursed if the worker pays the substitutes or helpers?  .  .    . . .  . .  . . . .  . .         . .    Yes No
   If “Yes,” by whom?
                                                                                                                       Form SS-8 (Rev. 5-2014)

Form SS-8 (Rev. 5-2014)                                                                                                                        Page 3
Part III Financial Control (Provide names and titles of specific individuals, if applicable.)
1  List the supplies, equipment, materials, and property provided by each party:
   The firm:
   The worker:
   Other party:
2  Does the worker lease equipment, space, or a facility?  . .  .     . . . .   . .    .      . . .     . .    . . . . .           Yes         No
   If “Yes,” what are the terms of the lease? (Attach a copy or explanatory statement.)

3  What expenses are incurred by the worker in the performance of services for the firm?

4  Specify which, if any, expenses are reimbursed by:
   The firm:
   Other party:
5  Type of pay the worker receives:     Salary                        Commission                  Hourly Wage                      Piece Work
         Lump Sum               Other (specify)
   If type of pay is commission, and the firm guarantees a minimum amount of pay, specify amount.       $
6  Is the worker allowed a drawing account for advances?     .  .     . . . .   . .    .      . . .     . .    . . . . .           Yes         No
   If “Yes,” how often?
   Specify any restrictions.

7  Whom does the customer pay? .    . . .     . .     . .    .  .     . . . .   . .    .      .   Firm                             Worker
   If worker, does the worker pay the total amount to the firm?       Yes         No          If “No,” explain.

8  Does the firm carry workers' compensation insurance on the worker?     . .   . .    .      . . .     . .    . . . . .           Yes         No
9  What economic loss or financial risk, if any, can the worker incur beyond the normal loss of salary (for example, loss or damage of equipment, 
   material)?

10 Does the worker establish the level of payment for the services provided or the products sold?  .    . .    . . . . .           Yes         No
   If “No,” who does?

Part IV  Relationship of the Worker and Firm
1  Please check the benefits available to the worker:    Paid vacations                         Sick pay               Paid holidays
         Personal days                        Pensions                           Insurance benefits                                Bonuses
         Other (specify)
2  Can the relationship be terminated by either party without incurring liability or penalty? . . .     . .    . . . . .           Yes         No
   If “No,” explain your answer.

3  Did the worker perform similar services for others during the time period entered in Part I, line 1? . .    . . . . .           Yes         No
   If “Yes,” is the worker required to get approval from the firm?  . . . . .   . .    .      . . .     . .    . . . . .           Yes         No
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         No
6  What type of advertising, if any, does the worker do (for example, a business listing in a directory or business cards)? Provide copies, if 
   applicable.
7  If the worker assembles or processes a product at home, who provides the materials and instructions or pattern?

8  What does the worker do with the finished product (for example, return it to the firm, provide it to another party, or sell it)?

9  How does the firm represent the worker to its customers (for example, employee, partner, representative, or contractor), and under whose 
   business name does the worker perform these services?

10 If the worker no longer performs services for the firm, how did the relationship end (for example, worker quit or was fired, job completed, 
   contract ended, firm or worker went out of business)?

                                                                                                                       Form SS-8 (Rev. 5-2014)

Form SS-8 (Rev. 5-2014)                                                                                                                     Page 4
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?  .   . . . . . .          . .     . . . . .       .  . .         .    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?  . . . . . .       .  . .         .    Yes No
     If “Yes,” whom did the worker pay?
     If “Yes,” how much did the worker pay?  .          . . . . .    . . . . . . .          . .     . . . . .       . $
8    Where does the worker sell the product (for example, in a home, retail establishment)?

9    List the product and/or services distributed by the worker (for example, meat, vegetables, fruit, bakery products, beverages, or laundry or dry 
     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?  .    . . . .    . . . . . . .          . .     . . . . .       .  . .         .    Yes No
11   Does the worker sell other types of insurance for the firm?  .  . . . . . . .          . .     . . . . .       .  . .         .    Yes No
     If “Yes,” enter the percentage of the worker’s total working time spent in selling other types of insurance  . .  . .         .                               %
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  . . .     . . . . .       .  . .         .                               %
13   Is the merchandise purchased by the customers for resale or use in their business operations?  .   . . .       .  . .         .    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.

                                                                                                                                   Form SS-8 (Rev. 5-2014)