Statement to Independent Contractor

  • This statement is not an agreement. If an employer-employee relationship exists, it cannot be changed by a written agreement. An employee cannot elect to be treated as an independent contractor if he is already in fact an employee.

  • This statement confirms that the individual listed below is not an employee for all or some combination of the majority of the following reasons:
    1. I do not control the hours that he works.
    2. I do not have the right to directly or personally supervise his work.
    3. I require that he provides all supplies and tools needed to perform his service.
    4. He has the right to provide his services to others of his customers.
    5. He has the right to send an employee of his in his place.

  • Since the individual listed below is not an employee, I will not withhold income tax. The individual below is autmatically responsible for paying his own income taxes and Social Security Tax.

  • I am required to file a form 1099-MISC to the IRS to report his earnings from me if the total amount is over $600 at the end of the year.

    Full name

    Social Security Number


    City State ZIP