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.Iorm 6-AC-02-1 . CERTIFICATION . TO: Rudolph Livingston Executive Director Department of Personnel 118 State Centennial Building 1313 Sherman Street Denver, Colorado 80203 RE: Personal Service Contract Classification The undersigned hereby certifies that the attached contract, Contract Routing No. , from the Department of Natural Resourc~s (Dept.) has been examined, and the follow~n9 have been determined concernlng t e correct classi- fication of the contractor undertaking the services and work which are the subject of the contract. The contractor is a firm or individu~l: (a) who is responsible for the results of the work to be undertaken, but is not subject to the Statels control as to the means and methods of accomplishing these results; ---X...... YES NO (b) who selects his clients and is free to work for one or more during any given interval; ---X- YES NO (c) who determines the time and place the work will be performed; ~YES NO (d) who provides the tools, materials and office space needed to perform the workj ---X- YES NO (e) who does not participate directly or indirectly in benefit programs of the State (for example, is not covered by the State for Workmen's Compensation insuring for injury to himself, for Public Liability insuring for injury to others, or for unemployment compensation)~ -1L- YES NO (f) who may agree to perform specific services for a fixed price and generally does not receive regular amounts at stated intervals. -1L- YES NO Affirmative responses to the listed classification indicia identify the services to be contracted as those of an independent contractor; negative responses as those of an (temporary) employee. Any negative response where the certified classification is that of an independent contractor will require, in addition, a qualification by written explanation accompanying this certification. If the explanation is not attached, the class~f~cation shall be presumed to be that of an employee. Accordingly, the attached contract is determined to be and is so certified as an independent contractor/~~~~~ (strike ~) contract. Executive Department of the records of this Department and inquiry of the con- is the history of any and all contracts entered into and the State during the last two years: Classification Beginning Date Ending Date of Contract Upon examination tractor, the following between the contractor SEE ATTACHMENT SIGNED this day of , 19_ STATE OF COLORADO DEPARTMENT OF NATURAL RESOURCES By Executive Director (Title)