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(Rev. August 2011)
Department of the Treasury
Internal Revenue Service

OMB. No. 1545-0004

Determination of Worker Status for Purposes
of Federal Employment Taxes and
Income Tax Withholding

For IRS Use Only:
Case Number:
Earliest Receipt Date:

Name of firm (or person) for whom the worker performed services

Worker’s name

Firm’s mailing address (include streetaddress, apt. or suite no., city, state, and ZIP code)

Worker’s mailing address (include street address, apt. or suite no., city, state, and ZIP code)

Trade name

Firm's email address

Worker's daytime telephone number

Worker's email address

Firm's fax number

Firm's website

Worker's alternate telephone number

Worker's fax number

Firm's telephone number (include areacode)

Firm’s employer identification number

Worker’s social security number

Worker’s employer identification number (if any)

Note. If the worker is paid for these services by a firm other than the one listed on this form, enter the name, address, and employer identification
number of the payer. ▶

Disclosure of Information
The information provided on Form SS-8 may be disclosed to thefirm, worker, or payer named above to assist the IRS in the determination process.
For example, if you are a worker, we may disclose the information you provide on Form SS-8 to the firm or payer named above. The information can
only be disclosed to assist with the determination process. If you provide incomplete information, we may not be able to process your request. See
Privacy Act andPaperwork Reduction Act Notice on page 6 for more information. If you do not want this information disclosed to other parties, do
not file Form SS-8.
Parts I–V. All filers of Form SS-8 must complete all questions in Parts I–IV. Part V must be completed if the worker provides a service directly to
customers or is a salesperson. If you cannot answer a question, enter “Unknown” or “Does not apply.” Ifyou need more space for a question, attach
another sheet with the part and question number clearly identified. Write your firm's name (or workers' name) and employer identification number (or
social security number) at the top of each additional sheet attached to this form.

Part I

General Information

This form is being completed by:


Worker; for services performed

to(beginning date)

(ending date)


Explain your reason(s) for filing this form (for example, you received a bill from the IRS, you believe you erroneously received a Form 1099 or
Form W-2, you are unable to get worker’s compensation benefits, or you were audited or are being audited by the IRS).


Total number of workers who performed or are performing the same or similarservices:
Employment Agency
How did the worker obtain the job?


Attach copies of all supporting documentation (for example, contracts, invoices, memos, Forms W-2 or Forms 1099-MISC issued or received, IRS
closing agreements or IRS rulings). In addition, please inform us of any current or past litigation concerning the worker’s status. If no income reporting forms
(Form1099-MISC or W-2) were furnished to the worker, enter the amount of income earned for the year(s) at issue $

Other (specify)

If both Form W-2 and Form 1099-MISC were issued or received, explain why.

Describe the firm’s business.

For Privacy Act and Paperwork Reduction Act Notice, see page 6.

Cat. No. 16106T

Form SS-8 (Rev. 8-2011)

Page 2

Form SS-8 (Rev. 8-2011)


General Information (continued)

If the worker received pay from more than one entity because of an event such as the sale, merger, acquisition, or reorganization of the firm for
whom the services are performed, provide the following: Name of the firm's previous owner:
Previous owner's taxpayer identification number:
Other (specify)
Description of above change:

Change was a:...
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