Printable Version

Independent Contractor Determination Form

Name of Business  ___________________________________________________________________

Please answer the following questions about the proposed independent contractor and discuss answers as appropriate.  Attach additional sheets if necessary.

Financial Control

1.

a) Is the proposed contractor a corporation?  _____  If so, please provide tax identification number. ____________________

b) If the proposed contractor is an individual, please provide the individual’s social security number. ____________________

c) Is the person a foreign national?  ________  If so, is the person a resident or non-resident alien?  _____________________

(Additional tax forms are required when contracting with a foreign national.)

2. Conflict of Interest:

a) To your knowledge is the contractor a CNM employee?  _______ or employed by CNM during the last 12 months?  _______________________________

b) To your knowledge is the person providing services a close relative of a CNM employee? _______________________________

c) To your knowledge does a CNM employee have a significant financial interest in the firm CNM is contracting with?   _______________________________ 

If the answer to any of these questions is yes, please explain and provide names and social security numbers of the parties involved.

3. To your knowledge has the contractor/service provider been suspended, debarred or ineligible from entering into contracts with the Executive Branch of the Federal Government, or is in receipt of a notice of proposed debarment from any State agency or local public body?

4. Does the proposed worker perform for other clients and solicit work from other clients?  ________  Please attach the worker/contractor’s brochure or resume (if available).

5. Is the proposed worker listed in the business pages of the telephone directory?  _________  Does the contractor have a NM gross receipts number? _________

6. Who is responsible for each of the following business expenses?

                                                                                                    CNM         Contractor             N/A

a) rent/utilities                                                                         ____       _________           ____

b) tools and equipment                                                          ____       _________           ____

c) training                                                                                 ____       _________           ____

d) advertising                                                                          ____       _________           ____

e) payments to business managers and agents                 ____       _________           ____

f) wages or salaries of assistants                                         ____       _________           ____

g) licensing/ certification/ professional dues                     ____       _________           ____

h) insurance                                                                             ____       _________           ____

i) postage and delivery                                                          ____       _________           ____

j) repairs and maintenance                                                    ____       _________           ____

k) supplies                                                                               ____       _________           ____

l) travel                                                                                     ____       _________           ____

m) leasing of equipment                                                        ____       _________           ____

n) depreciation                                                                        ____       _________           ____

o) inventory/COGS                                                                ____       _________           ____

7. Will the worker have unreimbursed costs?  If so, what costs will be unreimbursed?

Behavioral Control

8. Will the worker perform the service personally?  _____  With other individuals? _____  Of those individuals, whose employees are they?

9.  Will your department specify or require the following? (circle all that apply)

a) When to do the work

b) Where to do the work

c) What tools or equipment to use

d) What workers to hire to assist with the work

e) Where to purchase supplies or services

f) What work must be performed by a specified individual

g) What routines or patterns must be used

h) What order or sequence to follow

10. Does CNM maintain the right to provide and require the contractor to adhere to detailed instructions?

11. Does your department substantially control the detailed method of work?  _____  Result of work?  ______  If yes, please explain.

12. Will CNM provide periodic or ongoing training to the worker about procedures to be followed and methods to be used in performing the work?

Relationship of the Parties

13. How long will the worker be working on the project?

14. Will CNM provide the worker with benefits such as paid vacation days, paid sick days, insurance, retirement plan, IRC section 403(b), or cafeteria plan?

15. Can CNM terminate the work relationship at will without penalty?______________

Can the worker terminate the work relationship at will without penalty? _____________

16. Is the service you are requesting a part of the regular business of your area?  Explain how this does or does not involve your operation.

17. Has your department (or CNM )to your knowledge used this contractor before?   _______  Do you envision using this contractor again?  Please explain.

_____________________________________       __________________________      ________________________
Signature of person completing this form                     Extension                                                  Date

_____________________________________       __________________________
Signature of Control Agent                                             Date

_____________________________________       __________________________
Review of Determination                                                  Date