UC Merced Independent Contractor Approval Request Packet

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UC Merced Independent Contractor Approval Request PacketThis packet contains the required instructions and documentation to request approval to hire anIndependent Contractor/Consultant. Review and approval of IC status must be completed beforeany work is performed.Independent Contractor: The University has the right tocontrol only the results of the service, notthe manner of performance.Independent Consultant: The University does not controleither the results of the service or the manner ofperformance.Independent contractors: have no affiliation with the University have multiple concurrent clients, advertise theirservices in publications work on separate/distinct projects have invested in various business-relatedexpenses are engaged by the University to perform specificfunctions or tasks (deliverables) perform work outlined in a written contract are not given instruction on when, where or how toperform the work in order to produce a deliverable do NOT receive training, orientation or supervisionfrom the University use their own equipment and supplies to performcontracted work are “paid per job” will not receive employee benefits or superviseUniversity employees do not have to follow University scheduled hours ofworkIndependent consultants: have no affiliation with the University does not necessarily engage in consultationwith multiple clients at once provide management advice orrecommendations based on their technicalknowledge as a subject matter expert, typicallyin the form of a written or verbal report perform work outlined in a written contract are not given instruction on when, where orhow to perform the work in order to produce adeliverable do NOT receive training, orientation orsupervision from the University use their own equipment and supplies toperform contracted work are “paid per job” will not receive employee benefits or superviseUniversity employees do not have to follow University scheduledhours of workIf the work you are seeking does not fall within one of the two definitions above, pleasecontact Human Resources for further assistance.Documents Required for Independent Contractor/Consultant Approval:1. Independent Contractor Prehire Information formComplete Parts 1 through 4 of this form prior to engaging in independent contractor services. All sections ofthis form must be completed.2. Independent Contractor/Consultant’s CV/resume must be attached3. Federal Tax W9 Form4. Statement of WorkThe Statement of Work should clearly describe the work for this project, detail specific deliverables, keytasks, activities, and milestones, period of performance/completion timeframe, where the work will beperformed, rate of pay5. UCM Conflict of Interest Worksheet

INDEPENDENT CONTRACTOR PREHIRE INFORMATIONInstructions: Complete Parts 1 through 4 of this form. Failure to complete the following sections t ruthfully may result in statutory violations (e.g.Internal Revenue Service Code or California Public Contract Code) and may result in individual, department financial, or criminal penalties.PART 1 - To be completed by the Unit or DepartmentREQUESTING DEPARTMENTDepartment name:Date:Department contact:Phone #:E-mail:UCM projectmanager :Phone #:E-mail:PART 2PROPOSED CONTRACTOR INFORMATIONProposedcontractor:Phone #:Email:Address: (Street Address, City, State, Country, Zip)Has the University previously hired this Contractor?If yes, please provide a description of the services they provided:NoYesContractor's Social Security number (SSN) and/or Federal Employer ID Number (FEIN) should be provided on the attached W-9 form only.Is the individual a US citizen?YesNoIf using SSN and not a US citizen, provide:Visa type:Country of Citizenship:Note: If not a US citizen or US Permanent Resident, a Glacier Tax record must be completed, signed and submitted to Central Payroll prior topayment being processed.PROPOSED CONTRACT WORK INFORMATIONUse the attached Scope of Work document to provide in detail: specific deliverablesproject timeline with milestoneslocation of where the work will be performedWill work be performed on University property?YesNoWill University equipment or supplies be used?YesNoPeriod of performance:Start date:End date:Method of pay and rates: (e.g. 40 hours @ 50/hr or fixed fee 500):Not to Exceed Describe how and why the proposed contractor was selected, including any extenuating circumstances. A current CV/Resume must be attached.Is it expected that the University will hire this contractor as an employee upon the conclusion of proposed service?1 of 2YesNoClear Form

PART 3 – INTERNAL REVENUE SERVICE CLASSIFICATION FACTORS CHECKLISTAnswer the questions below by selecting either "yes" or "no" (one response per row) in the columns below. Additional detail regarding IRSclassification factors is available on our Business & Financial Services Page Explanations for any answer may be submitted on a separate sheet.CLASSIFICATION FACTOR TABLE (03/2 (( &2175 &725 A. Behavioral Control: Right to direct and control details and means by which contractor performs services. InstructionTrainingCONSULTANTWill the department give the individual instructions as to when,where, and how he or she is to perform the job?YesNoWill the worker receive training from the University?YesNoNoYesYesNoNoYesYesNoNoYesB. Financial Control: Right to direct and control economic aspects of the worker’s activitiesSignificant investmentPayment of expensesServices availableIncremental paymentRisk of profit or lossHas the worker invested in facilities such as office or equipment toperform the proposed services to commercial clientele?Will the University pay the worker’s business or travel expenses inaddition to the rate or fee?Does the worker make his or her services available to otherbusinesses?Will the University pay the worker by the hour, week, or monthrather than by the job?Will the worker bear the risk of making a profit or losing moneyunder this arrangement?C. Relationship of Parties: Intent of parties concerning status and control of worker.Is the work to be performed part of the regular business of theRegular University businessUniversity; teaching, research and public service?activityAgreement documentIndividual statusControl of individualYesNoWill a written agreement be executed between the University andthe individual describing the individual as an independentcontractor?YesNoWill the individual receive any UC employee benefits?YesNoYesNoYesNoYesNoYesNoYesNoYesNoWill the individual hire and supervise other persons on behalf of theUniversity?Is it a condition of the agreement that the individual personallyprovide service to the University?Can the individual terminate his/her relationship at any timewithout incurring any personal liability?Will the individual be submitting regular oral and/or writtenreports to the University, other than status updates?Will a University employee provide ongoing supervision to theindividual?Will the individual have to follow University scheduled hours ofwork?PART 4DEPARTMENT AUTHORIZATION AND CERTIFICATIONThe department hasAPPROVEDDENIED this request.By authorizing this transaction, the department authority warrants and represents that the information provided is true and correct.Department Head Authorized SignaturePrinted name:Title or position:Date:Phone #:Fax:Email:PART 5 – This section to be completed by Procurement Services and HR as needed:PROCUREMENT SERVICES DETERMINATIONComments:HUMAN RESOURCES DETERMINATIONReviewers comments:This request has itle: Date:Title: Date:2 of 2

W-9Form(Rev. October 2018)Department of the TreasuryInternal Revenue ServiceRequest for TaxpayerIdentification Number and Certification Go to www.irs.gov/FormW9 for instructions and the latest information.Give Form to therequester. Do notsend to the IRS.1 Name (as shown on your income tax return). Name is required on this line; do not leave this line blank.Print or type.See Specific Instructions on page 3.2 Business name/disregarded entity name, if different from above3 Check appropriate box for federal tax classification of the person whose name is entered on line 1. Check only one of thefollowing seven boxes.Individual/sole proprietor orsingle-member LLCC CorporationS CorporationPartnership4 Exemptions (codes apply only tocertain entities, not individuals; seeinstructions on page 3):Trust/estateExempt payee code (if any)Limited liability company. Enter the tax classification (C C corporation, S S corporation, P Partnership) Note: Check the appropriate box in the line above for the tax classification of the single-member owner. Do not check Exemption from FATCA reportingLLC if the LLC is classified as a single-member LLC that is disregarded from the owner unless the owner of the LLC iscode (if any)another LLC that is not disregarded from the owner for U.S. federal tax purposes. Otherwise, a single-member LLC thatis disregarded from the owner should check the appropriate box for the tax classification of its owner.Other (see instructions) 5 Address (number, street, and apt. or suite no.) See instructions.(Applies to accounts maintained outside the U.S.)Requester’s name and address (optional)6 City, state, and ZIP code7 List account number(s) here (optional)Part ITaxpayer Identification Number (TIN)Enter your TIN in the appropriate box. The TIN provided must match the name given on line 1 to avoidbackup withholding. For individuals, this is generally your social security number (SSN). However, for aresident alien, sole proprietor, or disregarded entity, see the instructions for Part I, later. For otherentities, it is your employer identification number (EIN). If you do not have a number, see How to get aTIN, later.Note: If the account is in more than one name, see the instructions for line 1. Also see What Name andNumber To Give the Requester for guidelines on whose number to enter.Part IISocial security numberThis sectionis not requiredfor––the Independent ContractororSubmission.Procurement willEmployer identification numbercollect TAX ID info once– approvedCertificationUnder penalties of perjury, I certify that:1. The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me); and2. I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal RevenueService (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified me that I amno longer subject to backup withholding; and3. I am a U.S. citizen or other U.S. person (defined below); and4. The FATCA code(s) entered on this form (if any) indicating that I am exempt from FATCA reporting is correct.Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding becauseyou have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For mortgage interest paid,acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement (IRA), and generally, paymentsother than interest and dividends, you are not required to sign the certification, but you must provide your correct TIN. See the instructions for Part II, later.SignHereSignature ofU.S. person Date General InstructionsSection references are to the Internal Revenue Code unless otherwisenoted.Future developments. For the latest information about developmentsrelated to Form W-9 and its instructions, such as legislation enactedafter they were published, go to www.irs.gov/FormW9.Purpose of FormAn individual or entity (Form W-9 requester) who is required to file aninformation return with the IRS must obtain your correct taxpayeridentification number (TIN) which may be your social security number(SSN), individual taxpayer identification number (ITIN), adoptiontaxpayer identification number (ATIN), or employer identification number(EIN), to report on an information return the amount paid to you, or otheramount reportable on an information return. Examples of informationreturns include, but are not limited to, the following. Form 1099-INT (interest earned or paid)Cat. No. 10231X Form 1099-DIV (dividends, including those from stocks or mutualfunds) Form 1099-MISC (various types of income, prizes, awards, or grossproceeds) Form 1099-B (stock or mutual fund sales and certain othertransactions by brokers) Form 1099-S (proceeds from real estate transactions) Form 1099-K (merchant card and third party network transactions) Form 1098 (home mortgage interest), 1098-E (student loan interest),1098-T (tuition) Form 1099-C (canceled debt) Form 1099-A (acquisition or abandonment of secured property)Use Form W-9 only if you are a U.S. person (including a residentalien), to provide your correct TIN.If you do not return Form W-9 to the requester with a TIN, you mightbe subject to backup withholding. See What is backup withholding,later.Form W-9 (Rev. 10-2018)

UCM Independent Contractor/ConsultantSTATEMENT OF WORK1.Sponsoring Department:2.Scope of Work: Be sure to include specific deliverables, project timeline with milestone, andlocation of where the work will be performed.3.Period of performance: to4.UCM Project Manager:5.Proposed Contractor:6.Does an Employee-Vendor Relationship exist?If yes, explain in space provided:7.Attach a copy of any written contract or agreement that exists between the University andthe Independent Contractor/ConsultantYESNO

UC PROCUREMENT SERVICESREPORT AND CERTIFICATION OF PROPOSED TRANSACTIONINVOLVING A POTENTIAL CONFLICT OF INTERESTEach individual or company offering to provide goods or services to the University must complete this form if that individual orcompany meets any of the below criteria:A. Are or owned by a current UC employee of any locationB. Are or owned by a former UC employee of any location, who has been separated for less than two (2) years (retired,dismissed, separated, or formerly employed)C. Are or owned by a current UC employee of any location, who owns or controls 10% or greater interest in a business thatwill provide goods or services to the UniversityD. Are or owned by a near relative of a current UC employee of any location (spouse, domestic partner or relative of thedomestic partner, child, parent, brother, sister, son‐in‐law, daughter‐in‐law, father‐in‐law, mother‐in‐law, brother‐in‐law,or sister‐in‐law of a University employee, and step‐relatives in the same relationship)E. Are or owned by a near relative of a current UC employee of any location, when that near relative owns or controls 10%or greater interest in a business that will provide goods or services to the UniversityF. Any UC employee will be paid by the proposed supplier for the proposed transaction.None of the above apply to me:If you are selecting "None of the above apply to me", type your name in the space provided and this form is considered completeFull Legal Name of proposed supplier:Name of UC Employee:Which of the above listed criteria (A‐F) best meets your situation?Please indicate which of the following is applicable:I am a:current UC employeeUC location where employedDepartment where employedDoes your position include teaching or research responsibilities?Job TitleYESNODescription of UC employment job duties:former UC employee, who has been separated for less than two (2) years (retired, dismissed, separated, or formerly employed)UC location where employedDepartment where employedJob TitleSeparation Date:near relative of a current UC employee (spouse, child, parent, brother, sister, son‐in‐law, daughter‐in‐law, father‐in‐law,mother‐in‐law, brother‐in‐law, sister‐in‐law, and step relatives and domestic partners in the same relationship)Name of relative (UC employee)Relationship to current UC employeeRelative’s UC Campus and DepartmentDoes your near relative UC employee’s position include teaching or researchresponsibilities?YESNOCurrent and former employees ONLY: Do you/Did engage in any of the negotiations, transactions, planning, arrangements, or any part of the decisionmaking process relevant to the transaction while employed by any University location?YESNOCurrent and former employees ONLY: Has any/Did any of your University time, University material, University equipment, or was University facilitiesused or will be used in connection with the proposed transaction?YESNORelatives of UC employees ONLY: Does your near relative have any past, current, or future responsibility for, involvement in, or direct or indirectinfluence on any of the negotiations, transactions, planning, arrangements, or any part of the decision making process relevant to the proposedtransaction?YESNOFor former employees ONLY: did you hold a policy‐making position in the same general subject area as the proposed transaction, during the lasttwelve (12) months of UC employment?YESNOIf you answered YES to any of the above questions, please explain. Attach additional sheet if needed:Rev. 1‐2020Page 1 of 2

Describe the goods and/or services:Have the goods and/or services already been provided to the UC?YESNOAre these goods and/or services available in the commercial market by other providers?YESNOI certify that the above information is true:Signature of UC employee, former UC employee, or near relative of current UC employeeDate:UC Department Certification ONLYAre these goods and/or services available from the University’s own facilities?YESNOHow did your department learn of this provider?Department Head NameSignatureDateUC LOCATION PROCUREMENT ONLYHas this supplier gone through the conflict of interest process before (check the COI database)?YESNOIf Yes, what was the determination?Procurement ManagerMaterial ManagerDateApprovesDeniesCheck here if the “UC Justification For Proposed Transaction Involving a Potential Conflict of Interest” is attachedRev. 1-2020Page 2 of 2

Documents Required for Independent Contractor/Consultant Approval: 1. Independent Contractor Prehire Information form Complete Parts 1 through 4 of this form prior to engaging in independent contractor services. All sections of this form must be completed. 2. Independent Contractor/Consultant’s CV/r