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SD EForm - 0776 V1    Complete and use the button at the end to print for mailing. To print a blank form, use print options provided by your browser

Worker Relationship Questionnaire

WORKER RELATIONSHIP QUESTIONNAIRE

South Dakota Department of Labor and Regulation
Reemployment Assistance
PO Box 4730
Aberdeen, SD 57402-4730
Phone 605.626.2312 • Fax 605.626.3347

INSTRUCTIONS: This information is required to determine whether a worker is an employee or an independent contractor (SDCL 61-1-11). This form should be completed for one individual who is representative of the class of workers whose status is in question. A separate Worker Relationship Questionnaire must be completed when a written determination is desired for more than one class of workers, or if the facts are materially different within the same class of workers.

This questionnaire must be completed and returned within two weeks.

FIRM: The individual, corporation, partnership, association or other type of organization for whom the services are performed.

WORKER: The person who performs the services.

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FIRM

Business Owner, Partners, Corporate Name and Contact Person is required.

Business Name is required.

Business Address.

Invalid Phone Number, format number as: 605-555-1234

FEIN is required.

Invalid Account Number, Please format account number as: 12345.6-7

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WORKER

Representative Worker name is required.

Worker's address is required.

Invalid Phone Number, format number as: 605-555-1234

SSN is required.

All Items must be answered or marked "Unknown" or "Does Not Apply". If you need more space, attach another sheet.

You must provide a description of the nature of the firm's business




You must provide a description of the service performed by the worker

The Date the working relationship started is required

The Date the working relationship ended is required

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If you answered yes, indicate what kind.

If you answered yes, indicate when.

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If you answered yes, you are required to give specific examples.

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If you answered no, please explain.

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If you answered no, please explain.




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If you answered Other, please explain.

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If you answered yes, please explain.

This field is required, please indicate who the worker reports to.

Field is required, when does the worker report to the individual specified?

Field is required, why does the worker report to the individual specified?

Field is required, how does the worker report to the individual specified?

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Required field, list the tools and equipment provided by the firm.

Required field, please indicate the value of the tools and equipment provided by the firm.

Required field, list the tools and equipment provided by the worker.

Required field, please indicate the value of the tools and equipment provided by the worker.

Required field, list the supplied and materials provided by the firm.

Required field, please indicate the value of the supplied and materials provided by the firm.

Required field, list the supplied and materials provided by the worker.

Required field, please indicate the value of the supplied and materials provided by the worker.

Required field, please indicate the business expenses incurred by the worker.

If Yes, specify the reimbursement expenses.

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Please check Firm or Worker

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If you answered "Other" please explain.

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If you answered "other" please specify.

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If you answered "other" please specify.

Required, please provide the name of the individual who writes the paycheck.

Required, please indicate if the worker is paid hourly, weekly, or monthly.

The total amount paid is required.

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If you answered "Yes" please specify.

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If you answered "Other" please specify.

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If you answered "Yes" indicate the type of insurance.

Required, please indicate the approximate hours a day or week the worker provides services for the firm.

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If you answered "Yes" please indicate for whom?

If you answered "Yes" indicate the number of workers in the past year?.

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If you answered "No" please explain.

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If you answered "No" please explain.


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If you answered "No" please explain.

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If you answered "Other" please specify.

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If you answered "Other" please specify.

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If you answered "Yes" please indicate how.

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If you answered "Yes" please indicate where.

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If you answered "No" please indicate how the worker is represented.

You are required to indicate how the firm learned of the worker's services.

Required, how long has the worker performed services for the firm's business?


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If you answered "yes" please indicate what kind.

If you answered "yes" please indicate by whom is it issued.

If you answered "yes" please indicate by whom the fee is paid

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If you answered "yes" specify and give amounts of the investment.

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If you answered "yes" please indicate how.

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Required, provide details to indicate why you believe the worker is an independent contractor or is an employee of the firm.


You must type your name before printing.

You must provide your Title.

Address (PO Box/Street) is required

City is required

State is required

Invalid Zip Code: Make sure the zip code is in the standard US or Canadian format

Invalid Phone Number, format number as: 605-555-1234