Lembi Kongas 1/23/2018 - Laserfiche WebLink

Key: EE = Indicates Employee IC = Indicates Independent Contactor YES NO 16 Has the worker invested in the equipment or facilities used in performing (1-6- EE services? 17 Does the worker have a right to realize a profit or have a significant risk of loss? IC EE 18 Does the worker perform the same type of services for several persons or firms? IC EE 19 Does the worker offer services to the general public on a regular basis? IC EE 20 Does the employer have the right to discharge the worker at will? EE Q.C) 21 Does the worker have the right to quit without incurring liability? IC 22 Does the worker perform services only pursuant to written contracts? IC EE 23 Has the worker attained business registrations, professional occupational licenses IC EE or certificates required by law to perform contracted services? 24 Has the worker purchased worker's compensation insurance and paid taxes IC EE required for an independent business? 25 Does the worker maintain a separate set of books or records, reflecting all items IC EE of business income and expenses of an independent business? 26 Has the worker assumed financial responsibility for any defective workmanship or IC� EE for services not provided? Section 3: Your Conclusion and Comments BYES Is the worker an independent contractor? If yes, is the independent contractor: ❑NO Retired from a WA state retirement system? [ YES ❑NO EVES Is the worker an employee? If yes, is the employee: le NO YES Working in an eligible position? R Np Retired from a WA state retirement system? 0 NO Note: Report all employees who retired from a WA state retirement system to DRS. Report independent contractors if they retired under the 2008 early retirement factors and they are under age 65. Comments: Employer Representative Name and Title(Please print) �- 1/2. E544-Z.2 s .a /d Employer Representative Signat Date eep this questionnaire to assist in documenting independent contractor status. DRS MS 344(R 5/09) Page 2 of 2