New Jersey Department of Labor & Workforce Development
Division of Employer Accounts
Audits and Field Services
WORKER CLASSIFICATION QUESTIONNAIRE
An unemployment tax audit involving the company listed below disclosed payments to you for services provided to the company.
The following information is needed to determine if your relationship with the company was that of an independent subcontractor or
an employee for purposes of Unemployment Insurance. The completed questionnaire should be returned in the enclosed self-
addressed envelope by the date indicated. Failure to return the questionnaire may result in an Auditor or Investigator scheduling an
appointment with you for the purpose of securing this information. If you have any questions, contact the Auditor or Investigator
whose business card is attached.
NAME OF COMPANY:
ADDRESS OF COMPANY:
DATE OF SERVICE UNDER REVIEW:
NAME OF INDIVIDUAL:
INDIVIDUAL’S SOCIAL SECURITY NUMBER:
DUE DATE OF COMPLETED QUESTIONNAIRE:
1. Type of business entity you operate: sole proprietorship corporation
partnership other
If a corporation or partnership, enter your Federal Employer Identification Number:
2. Type of work company indicated above does: (for example, carpenter, roofer, computer consultant,
accountant – be specific)
Type of work you provided for this company: (for example carpenter, roofer, computer consultant,
accountant – be specific)
3. Do you have helpers on the job or do you work alone?
yes work alone
If you have helpers, were they:
hired by you supplied by the company
Were the helpers paid by:
you the company
4. Are you required to provide all services to the company or can you send a replacement?
can hire & send a replacement I must perform all services don’t know, never happened
5. For the dates of services indicated above, did you have other clients that you provided services to?
yes no if yes, how many others?
6. Approximately what percentage of your total self-employment income was from the company identified
above for the period under review?