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?
7. List any specialized equipment you use in your business?
Is this equipment
owned or supplied by you supplied by the company
8. Do you have a business location from which you operate other than your home?
yes no
9. Do you have a business phone number?
yes no If yes give number: ( )
10. Do you have a business license or certificate to operate your business?
yes no
If yes, type of license
11. Is your business registered in the county in which you operate?
yes no
12. Are you required to work any fixed hours?
yes no
13. Do you normally incur expenses in operating your business?
yes no
If yes, please indicate types of expenses
14. For the company listed above, do you provide materials if needed, or are materials provided by the
company?
company provides material supply own material not applicable
15. How is payment for services determined?
hourly wage piece work negotiated price per job commissions other (specify)
16. Do you have any of the following?
business cards printed invoices liability or business insurance
Schedule C – business tax return
Please submit a sample if you have any of the above, and a copy of your Schedule C for the period
under review
17. How do you advertise your business?
Yellow page/phone book listing newspaper private mailings professional journals
do not advertise other (please specify)
CERTIFICATION
: I certify all statements submitted are true, correct and complete to the best of my knowledge
and belief.
Name (please print): ______________________________ Signature: ___________________________
Date: ________________ Phone Number: _____________________________
Chrome Web Store
It looks like you haven't installed the Fill Chrome Extension Add to Chrome