Fillable University of Southern Mississippi - Independent Contractor Determination Questionnaire

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University of Southern Mississippi - Independent Contractor Determination Questionnaire

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Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.6707, fax www.pers.ms.gov
Employee vs. Independent Contractor Determination Questionnaire
Revised 08/02/2016
Please print or type in black ink. Completed form should be mailed or faxed to PERS. See bottom of form for contact information.
Information gathered on this questionnaire is used to determine whether a worker is an employee under the common-law rules for purposes of mandatory
coverage in the Public Employees’ Retirement System of Mississippi (PERS) or whether a PERS service retiree who is reemployed is subject to the reemployment
limitations as provided in Miss. Code Ann. §25-11-127 (1972, as amended). The employer in question should fully complete sections 1, 2, and 3, and the worker in
question should fully complete Section 4. The employer should submit the completed questionnaire with the appropriate documentation to PERS. If required by
the employing employer, submit the completed questionnaire with the appropriate documentation as noted below to the employing employer’s
department of human resources management for review prior to submitting to PERS.
Employer Information
Employer Name: ____________________________________________________________ Employer No.: ________________ - ___________________
Employer Representative’s Name: ________________________________ Employer Representative’s Title: _____________________________________
Employer Representative’s Phone: _________________________ Fax: _________________________ E-Mail: __________________________________
Mailing Address: ___________________________________________ City: ___________________________ State: ________ Zip: _______________
Worker Information
First Name: _______________________________________ MI: ______ Last Name: _______________________________________ Gender: M F
Social Security No.: ____________________________ Birth Date mm/dd/ccyy: _____________________ E-Mail: ________________________________
Mailing Address: ___________________________________________ City: ___________________________ State: ________ Zip: _______________
Phone: _______________________________ Cellular Home Work Phone: _______________________________ Cellular Home Work
Position/Employer from which Retired: ______________________________________________ Retirement Date mm/dd/ccyy: ______________________
Period of proposed engagement From mm/dd/ccyy: __________________________________To mm/dd/ccyy: _________________________________
Questions for the Employer
1. Describe in detail the work to be performed or services to be provided by the worker. Or attach a copy of the statement.
2. Have the services to be performed by the worker been performed previously by an employee of the employer? ........................................ Yes No
3. Has the worker ever performed these services as the employer’s employee? ........... Yes If yes, list years: ___________________________ No
4. Is the worker required to perform the services personally? ........................................................................................................................... Yes No
5. Describe the worker’s daily routine (i.e., schedule, hours, etc.).
6. Does the employer set or regulate the hours the worker will work or is required to work? ............................................................................ Yes No
7. Does the employer require services be performed by the worker on the employer’s premises? ................................................................... Yes No
8. At what location(s) does the worker perform services (e.g., employer’s premises, personal office, etc.)? Indicate the appropriate daily percentage of
time the worker spends in each location, if more than one.
_______________________________________________________________________________________________________________________
9. Describe any meetings or training the worker is required to attend and any penalties for not attending.
_______________________________________________________________________________________________________________________
Employee vs. Independent Contractor Determination Questionnaire – Revised 08/02/2016 Page 2 of 3
Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.6707, fax www.pers.ms.gov
10. How does the worker receive work assignments?
11. Who determines the methods by which assignments are performed?
_______________________________________________________________________________________________________________________
12. If substitutes or helpers are needed, who hires them? If the worker hires the substitutes or helpers, is approval by the employer required?
_______________________________________________________________________________________________________________________
13. Worker paid: Select one. $ _______ Hourly $ _______ Weekly $ _______ Monthly $ _______ Other ______________________
14. Specify what, if any, employer-funded benefits (e.g., sick leave, insurance, vacation, etc.) the worker will receive:
_______________________________________________________________________________________________________________________
15. Will the employer pay or reimburse the worker’s expenses? ....................................................................................................................... Yes No
If yes, on what basis?
_______________________________________________________________________________________________________________________
16. List the supplies, equipment, materials, and property provided by each party:
Employer: _______________________________________________________________________________________________________________
Worker: _________________________________________________________________________________________________________________
17. Is there a written contract between the worker and the employer to provide these services? ....................................................................... Yes No
If yes, please attach a copy of the contract.
18. Upon termination of the relationship, is the worker afforded due process rights? ......................................................................................... Yes No
19. Does the relationship between the worker and the employer contemplate continuing or recurring work? ..................................................... Yes No
20. Worker presented to employer customers and employees as: Select one.
Employee Representative Contractor Other ______________________________________________________
21. Will the worker receive an Internal Revenue Service Form 1099 for payments made by the employer? ..................................................... Yes No
22. Will the worker’s services be fully integrated into the business operations because the services
are important to the success or continuation of the employer? .................................................................................................................... Yes No
23. Check one of the following:
I have made personal inquiry and confirmed that my employer did not have a prearranged agreement prior to the retirement with the above-
named worker/PERS retiree to return to work in any capacity following his or her retirement.
I have made personal inquiry and confirmed that my employer did have a prearranged agreement prior to the retirement with the above-named
worker/PERS retiree to return to work in some capacity following his or her retirement.
The above-named worker is not a PERS retiree.
I understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a retirement plan administered by PERS
in an attempt to defraud the plan may be subject to criminal prosecution. With that understanding, I certify that the above information is true and correct.
Employer Representative’s Signature _______________________________________________________ Date mm/dd/ccyy: ___________________
Employee vs. Independent Contractor Determination Questionnaire – Revised 08/02/2016 Page 3 of 3
Public Employees’ Retirement System of Mississippi
429 Mississippi Street, Jackson, MS 39201-1005 800.444.7377 601.359.3589 601.359.6707, fax www.pers.ms.gov
Questions for the Worker
1. Do you currently, or do you plan to, work for any other PERS-covered employers while you are concurrently working for this employer? .... Yes No
If yes, list those covered employers and whether you work (will work) as an employee or independent contractor. If needed, continue listing on a
separate sheet of paper and attach.
Employer: _____________________________________________________________________________ Employee Independent Contractor
Employer: _____________________________________________________________________________ Employee Independent Contractor
Employer: _____________________________________________________________________________ Employee Independent Contractor
Employer: _____________________________________________________________________________ Employee Independent Contractor
2. Do you concurrently perform substantially similar services for more than one employer? .......................................................................... Yes No
If yes, list the other employers and services performed on a separate sheet and attach to this form.
3. Do you advertise your services? ........................................................................................................................................................................... Yes No
If yes, attach examples of advertising and list advertising media used.
4. Have you performed services for this employer previously? ........................................................................................................................ Yes No
If yes, list capacity of services (e.g., position, title, job duties, etc.) and whether you were employed as an employee of this employer during this time.
Capacity: ___________________________________________________________________________________ Employee Not an Employee
Capacity: ___________________________________________________________________________________ Employee Not an Employee
Capacity: ___________________________________________________________________________________ Employee Not an Employee
Capacity: ___________________________________________________________________________________ Employee Not an Employee
5. Does the employer have the right to control, supervise, or direct your performance of the services? ........................................................... Yes No
6. Check one of the following:
I am a PERS retiree and I did not have a prearranged agreement prior to my retirement that I would return to work in any capacity after retirement
with an employer participating in PERS.
I am a PERS retiree and I did have a prearranged agreement prior to my retirement that I would return to work in some capacity after retirement
with an employer participating in PERS.
I am not a PERS retiree.
If I did have a prearranged agreement prior to my retirement to return to work after retirement with an employer participating in PERS, I have fully
disclosed in writing to PERS the details of that agreement. I understand that any prearranged agreement could result in the voiding of my retirement
benefit.
I understand that I have a duty now and in the future to disclose in writing to PERS my employment in any capacity with an employer participating in
PERS and whether I have accepted employment under a personal services contract (including as an independent contractor) with an employer
participating in PERS.
I understand that I have a duty now and in the future to disclose in writing to PERS if I have accepted employment with a private leasing company,
temporary staffing agency, or any other such company where employment means I will be performing work for an employer participating in PERS.
I further understand that any person who makes a false statement or shall falsify or permit to be falsified any record of a retirement plan administered by
PERS in an attempt to defraud the plan may be subject to criminal prosecution. With that understanding, I certify that the above information is true and
correct.
Worker’s Signature: ____________________________________________________ Date mm/dd/ccyy:_____________________________________
To Be Completed by PERS
After thorough review of the provided information and attachments and for purposes of employment with a PERS-covered employer, the individual listed by
name on page 1 of this questionnaire has been determined to be an: ..................................................................... Employee Independent Contractor
PERS Reviewer’s Signature: _________________________________________________ Date mm/dd/ccyy:_____________________________________
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University of Southern Mississippi - Independent Contractor Determination Questionnaire

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Completed 21 April 2020

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