PROJ02103

• Contract/PO #: P.O. 11902
• Loan Projects - Doc Type: Contract Documents

'IndependentCContractor Certification"

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The contractor is a [mn or individual which:

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1. is responsible for the resUlts of the "vork to be undertaken, but is not subject to the state's
, control as to the means and methods of acComplishing these results;

X Yes No

2. selects his clients and is free to work for one or more during any given interval;

X Yes No

3. determines the time and place the work will be performed;

X Yes No

4. provides the tools, materials and office space needed to perform the work;

x Yes No

5. agrees to perform specific services for a fixed price and does not. receive regular
payments at stated intervals.

X Yes No

6. If the contractor is an individual, has he or she previously been an employee of the state?

Yes X No

If yes, give last date of employment. '.

Affmnative responses to items 1 through 5 indicate that the'relationship is that of an independent
contractor. For any negative response submit a written explanation.

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