The information provided below will assist Human Resources in determining whether the individual
performing the services will be classified for Federal, State and FICA tax purposes as an employee of MCC or
as an independent contractor. A copy of the approved form will be returned to you, the hiring manager, so
you may take appropriate action.
I have attached the Independent Contractor Questionnaire, a proposed Service Agreement, and any
supplemental information which supports the independence of the individual.
I understand that defining the proper status of the individual depends on the manner in which the work is
performed and on the nature of the relationship between the individual and MCC personnel responsible for
the work being performed. The status of the individual as either an independent contractor or an employee
may change if or when the manner in which the work is performed changes or the relationship between the
individual and MCC changes. I agree to notify the Human Resource Department if either of these changes
By my signature, I confirm that the information provided in the attached documents is truthful, that I have
sufficient knowledge of and responsibility for the work to be performed under this contract, and have the
authority to submit this individual for classification as either an employee or independent contractor.
Printed name of individual performing services: _____________________________________________
Department for whom services are to be performed: _____________________________________________
Printed name of responsible hiring manager: _____________________________________________
_____________________________________ _____________________________________________
Signature of responsible hiring manager Title
_____________________________________ _____________________________________________
Date Phone Number
To be reviewed and completed by MCC Human Resource Department:
I certify that I have reviewed the attached Independent Contractor Questionnaire Form and supporting
documentation and find the individual named to perform the described services to be (in regards to federal
employment tax withholding and related reporting purposes):
An Independent Contractor An Employee
_____________________________________ _____________________________________________
Printed name of HR reviewer Title
_____________________________________ _____________________________________________
Signature Date
Human Resources | Revised October 8, 2018
click to sign
click to edit