INDEPENDENT CONTRACTOR DECLARATION
(to be completed by the independent contractor)
The Internal Revenue Service segregates workers into two categories – employees and independent
contractors. Employees have an on-going relationship with their employer and are paid through a
payroll process. The employer withholds and pays to the IRS certain employment taxes. Independent
contractors provide particular services to the general public and are paid by the job. They are
responsible for all their own employment taxes. Payment to them is made through the accounts
payable system initiated by a purchase order/agreement and no taxes are withheld.
IRS regulations require that independent contractor status be verified. Please read the following
statements and sign this form if the statements are true and reflect the nature of your relationship with
Fairmont State University.
As an independent contractor,
1. I
am responsible for all employment taxes associated with the income I earn.
2. I provide services to the general public and generally work for more than one employer
d
uring the year (If available, attach your business card or other proof).
3. I maintain my own place of business separate from Fairmont State University.
Signature: ____________________________________________
Date: ________________________________________________
Rev. 10/2019
Printed Name: ________________________________________
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