Employee Certification Form~1.doc

ITS77 EMPLOYEE CERTIFICATION FORM

This form must be completed by the Resource’s Employer. One copy must be provided to the Resource for submission to the Commonwealth Agency for whom the Resource is providing services on their first day of work with that agency. One copy must be provided to the ITS77 Contractor under whose auspices the Resource is providing services to the Commonwealth.

Resource Name:

Resource Employer

Company Name:

Company Address (Street, city, state, zip):

Company Tax Identification Number:

Contact Information: Name:

Tel. #:

As the Resource employer:

1. Do you certify that you have a valid worker’s compensation insurance policy?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

If “Yes”:

Name of Carrier:

Policy Number:

Policy Effective Date:

If no, does the Resource employer have an exemption from the requirement to hold worker’s compensation insurance that would cover the Resource named above?

FORMCHECKBOX

Yes

FORMCHECKBOX

No If “Yes”:

Attach copy of document providing exemption

Resource is not eligible to provide services under ITS77 unless the Resource Employer has a valid worker’s compensation insurance policy or the Resource employer has an exemption covering the Resource.

2. Do you contribute to the Massachusetts unemployment insurance system, or the insurance system of the State where you, as the Resource Employer, are registered?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

If “Yes”:

DUA Account Number:

If no, is the Resource employer exempt from the requirement to contribute to an unemployment system that would cover the Resource named above (for example, in Massachusetts, a single member LLC)?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

If “Yes,” attach a document explaining the exemption, citing any applicable laws and/or regulations.

Resource is not eligible to provide services under ITS77 unless the Resource Employer contributes to an unemployment insurance system or the Resource employer has provided sufficient documentation to demonstrate that it is exempt from any requirements to provide unemployment insurance. For a single person corporation, LLP, or LLC, a notarized letter must be provided attesting to the fact that the organization does not employ more than one individual.

3. Do you certify that your company operates in compliance with all applicable Massachusetts and Federal laws regarding health insurance for employees?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

Resource is not eligible to provide services under ITS77 unless the Resource Employer answers “yes” to Question 3.

4. Do you certify that you will be withholding and remitting federal and state taxes, as well as Medicare, with each payroll cycle? FORMCHECKBOX Yes

FORMCHECKBOX

No

Resource is not eligible to provide services under ITS77 unless the answer is “Yes.”

5. Do you certify that you will fulfill all other employer obligations for this employee, including payment of any additional state and federal taxes?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

Resource is not eligible to provide services under ITS77 unless the answer is “Yes.”

6. Additional Information Required If Resource’s Employer Is A Single Member Limited Liability Corporation (“LLC”)

a. On what date was the LLC Organized?

b. Has the LLC provided services to clients other than clients obtaining the Resource's through a Statewide IT Services Contract? FORMCHECKBOX Yes

FORMCHECKBOX

No

Resource is not eligible to provide services under ITS77 if the LLC was organized fewer than 6 months prior to the engagement offer date and has provided services to clients other than those obtaining the Resource’s services under a Statewide IT Services Contract.

7. Do you certify that you will report any changes in the information above to both the Resource and the ITS77 Lower Overhead Contractor listed below, within 10 days of the change occurrence?

FORMCHECKBOX

Yes

FORMCHECKBOX

No

Resource is not eligible to provide services under ITS77 unless the answer is “Yes.”

All parties signing below agree that the Resource is not an employee of the Commonwealth:

ITS77 Contractor

Company Name:

Signature: ______________________________________________

Print Name of Signatory:

Date:

Resource Employer (if different from ITS77 Contractor) Company Name:

Signature: ______________________________________________

Print Name of Signatory:

Date:

Resource

Signature: ______________________________________________

Print Name of Signatory:

Date:

Category 2a Lower Overhead ONLY – for Resources where the Category 2a company (not a third party) is the Resource’s Employer:

First payment cycle (based on hourly rate):

FICA payment: FUTA payment: SUTA payment:

Workman’s Comp Payment: Other taxes: Specify type of tax:

Monthly insurance paid by employer:

Hourly Bill Rate: Hourly Pay Rate: (include any taxes withheld and paid on behalf of the Resource as part of the Hourly Pay Rate)

RFR ITS77StaffAug Page 3

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