Personal Services Contract
UMPQUA COMMUNITY COLLEGE, hereafter referred to as COLLEGE, and _____________________________, hereafter
referred to as CONTRACTOR, agree to the following terms and conditions for the purpose of rendering the following
Schedule of Services and Payment: CONTRACTOR will comply with the following schedule in performance of service or
delivery of product:
Services to begin (Date):_________________________________ Completion Date:______________________________
Interim progress payment (optional):
Date ____________________ Service ________________________________ Amount _________________________
Date ____________________ Service ________________________________ Amount _________________________
PAY TOTAL _________________________
1. Independent Contractor Certification: Prior to payment rendered, CONTRACTOR certifies:
A. I am not an employee of Umpqua Community College and have not been employed by COLLEGE in the last
twelve (12) months. I therefore waive any and all claims to benefits otherwise provided employees, including, but
not limited to: medical, dental, or other health insurances, retirement benefits, unemployment benefits, liability
insurance, or workers’ compensation insurance.
B. The services provided are not supervised by COLLEGE, and the only demand on time is faithful performance and
delivery of described services by specified deadline.
C. I am , am not licensed by the State or other political subdivisions to provide similar services for other
customers. My license number is ________________________. My Federal Tax ID# is ___________________.
If no ID#, give SS# ___________________.
D. I understand that I am solely responsible for federal and state taxes and social security payments applicable to
monies received for services herein rendered. I understand IRS Form 1099 will be filed on payments received
when appropriate.
E. No services are to be performed until this certification data is received and approved by the Finance Office and
authorized by a purchase order.
F. Payment will be made by the Finance Office after receipt of invoices and verification from the originating
department that the specified services have been satisfactorily performed.
2. The parties of this contract understand that an independent CONTRACTOR is not eligible to receive worker’s
compensation benefits unless said person has obtained coverage for such benefits pursuant to ORS 656.128. If
CONTRACTOR is performing the services with the help of others, it is understood that CONTRACTOR is responsible
to obtain and maintain in full force workers’ compensation insurance for involved parties and file a Certificate of
Workers’ Compensation with this form.
3. CONTRACTOR agrees to indemnify and hold harmless COLLEGE for any damages, expenses, costs and
disbursements, and attorney’s fees incurred as a result of CONTRACTOR’S negligence in performance of the
services or duties for which he/she is contracted. The COLLEGE strongly recommends that CONTRACTOR has in
effect professional liability insurance for protection against errors and omissions in performing this work.
$ 0.00
4. Other conditions: _______________________________________________________________________________
___________________________________________ ____________________________________________
Budget Administrator’s Signature Date Contractor’s Signature Date
___________________________________________ ____________________________________________
Budget Administrator’s Name (type or print) Contractor’s Name (type or print)
___________________________________________ ____________________________________________
Budget Code to be charged Street Address
___________________________________________ ____________________________________________
VP of Administrative Services Signature Date City State Zip
Submit to Finance Office signed W9, one signed copy of this agreement and independent contractor
checklist. When approved, copies will be returned to department.
Financial Office Use Only
Finance Office Approval Date