Virgin Islands Department of Labor

Virgin Islands Department of Labor Division of Unimployment Compensation P.O. Box 3159, Charlotte Amalie, St. Thomas, V.I. 00803 2353 Kronprindsens Gade, St. Thomas, V.I. 00803 INDEPENDENT CONTRACTOR ANALYSIS NOTE: A separate form should be completed for each job class to be ruled upon. This Form is Being Completed By: 441 Firm Worker Naza_tkddyu ‘: _n 1: --„v.,t., N Na.-k-r-c.4—, cm ,. \ c, c..----..5,,,N s -s•,- - Describe the Nature of the Firm's Business: Name of ClatmantANorker (if applicable). — Worker's Federal Employer Identification Number (if applicable): SSN: Job Title (only one per form): LA M b c rAP raf e Dates of Work of ClaimantANorker From 9 2-4/ 2.0 11 To 2.12_q19 ITEMS A - F BELOW ARE TO BE COMPLETED BY THE FIRM ONLY A) UC Account Number of Firm (if applicable): B) Form of Organization: I= Sole Proprietorship O Partnership In) Corporation a Others (specify) LLC C) Total numti:t workers in this class considered Independent Contractors 0) Total rIUMNAr of workers in this class considered employees: 2. E) If you have both, please explain why: ft4flirrt - e-S — kt&I grAi tit LONA T5f/M OFWATIoiss of 1Ht tsLa.3bS/caireAC-R;q2s- azi pt, FRS /2-4o s P7iZa-r N2 atip te ftr-MCGTs Cit3 krbiA3 14.ntsccatib gY 'tee og IS F) What was the first date the workers in this job class perforrned services of any kind for the firm: COMPL2..) .5.e/cicr 2OL9- INSTRUCTIONS FOR BOTH THE FIRM AND THE WORKER Attach copies of any written agreements, billing statements, applications, or contracts between the firm and the worker. If the agreement was oral, please reduce It to wilting and attach. If any State or Federal Agency has ruled on the same Job class as this worker or another of the same job class, attach a copy of the ruling. (These documents will not be returned.) Attached: EFTA00798211 ALL QUESTION MUST BE ANSWERED This Form is Being Completed By: Finn Worker 1. Is the work performed at the place of business of the firm? r Yes No 2. Can the worker work for a competitor? Yes a_ 3. Can the worker incur a loss from services performed? es No 4. Does the worker: use his/her own equipment, or facilities to provide the services (excluding transportation and hand tools)? Yes o 5. Are the workers business or travel expenses reimbursed by the firm? Yes o • rNo 6. Is training provided by, or at the direction of, the firm? Yes 7. Are the worker's services part of the day to day operations of the firm? yes—.. c Wo 8. Must the services be rendered personally? ..A3-) i.---Ero No \- •. .-1 9. Is there a continuing relationshifl between the worker and the firm for whom services are performed? Yes --- -',. 10. Are there set hours of work? Yes ' No 11. Is the worker required to comply with the firm's instructions about: A) When the work is to be done? B) How the work is to be done? . No es No 12. Is the worker required to work the regular business hours of the firm? r No 13. Is the worker required to keep the firm informed of the progress of the work? ' Ye No 14. Does the worker bill the firm for services performed? . es No 15. Is the worker paid by: A) Salary (hourly, weekly, or monthly)? 8) Commission? C) The Job? f (filo" 'hie NQ clsIC 1/4. o . s (No ..—....., Yes ) 'es Yes 16. Does the firm provide the worker with: A) Health or Life Insurance? 8) Vacation or Sick Pay? C) Retirement Benefits? Yes Yes Yes 17. Does the firm direct the sequence in which the work must be done? Yes No 18. Are the worker's services available to the general public? A) If yes, does the worker advertise? B) If yes..does the worker carry business liability insurance? Yes No Yes No Yes No 19. Can the worker be discharged at any time without the firm incurring a work contract penalty? „Les) No 20. Is the worker responsible for redoing defective work without additional compensation? Yes No 21. Questions for Salespersons: A) Does the worker sell: 1) Merchandise for resale or business supplies? 2) Consumer products or services directly to individuals? (If yes, attach a copy of any written agreement.) B) Does the worker sell full time for the firm? C) Can the worker sell for a competitor? D) Is the worker required to make an investment? (other than travel expenses and transportation) E) May the worker be penalized for not attending sales meetings? Yes No Yes No Yes No Yes No Yes No Yes No Page 2 of 3 EFTA00798212 23. The worker was an C employee independent contractor (please check the correct one) while working for the firm. Please eitplain the reasons for your answer. P war-ima6tcot_/ss b-1.buort-eb fr oM toldIV-Sclpectlainice COISIT/Y-11)g. Os / m Ata FOM Tha li\V2i9POK Mir A PP-MANst\\T ftsMOM - FOST k-kanC4 R2-LOW NECECUS I have reviewed this questionnaire, including accompanying documents. and to the best of my knowledge and belief, the facts and true and correct. Firm's Representative's Signature ClaimanWVorker's Signature Auditor/Claimstaker Date Comments: Title Page 3013 EFTA00798213