Sample Exhibit 3 - Certification Statement for Corporation or Independent Contractor.pdf

CAO 5/2/2022

Exhibit 3

EXHIBIT 3

MULTNOMAH COUNTY CONTRACT

Contract No. [[ Contract Number ]]

Certification Statement for Corporation or Independent Contractor Instructions: Please complete both sections below. Example: If Contractor is a Limited Liability Company, please check the “Limited Liability Company” box in Section A and check the “NOT APPLICABLE” box in Section B. Or, if Contractor is an Independent Contractor, then check “NOT APPLICABLE” in Section A, and check at least three (3) boxes in Section B to establish that the Contractor is an Independent Contractor.

A. CONTRACTOR IS A CORPORATION, LIMITED LIABILITY COMPANY, OR A PARTNERSHIP.

I certify under penalty of perjury that Contractor is a (check one):

☐ Corporation ☐ Limited Liability Company ☐ Partnership ☐ Non-Profit Corporation authorized to do business in the State of Oregon ☐ NOT APPLICABLE – See section B.

B. CONTRACTOR IS A SOLE PROPRIETOR WORKING AS AN INDEPENDENT CONTRACTOR.

Contractor certifies under penalty of perjury, that the following statements are true:

1. If CONTRACTOR is providing services under this Contract for which registration is required under ORS Chapter 671 (architects and landscape contractors) or 701 (construction contractors), CONTRACTOR has registered as required by law.

2. CONTRACTOR is free to determine and exercise control over the means and manner of providing the service, subject to the right of the County to specify the desired results.

3. CONTRACTOR is responsible for obtaining all licenses or certifications necessary to provide the services.

4. CONTRACTOR is customarily engaged in providing services as an independent business.

CONTRACTOR is customarily engaged as an independent contractor if at least three of the following statements are true.

NOTE: Check all that apply. You must check at least three (3) to establish that you are an independent contractor.

☐ A. CONTRACTOR’s services are primarily carried out at a location that is separate from CONTRACTOR’s residence or primarily carried out in a specific portion of the residence which is set aside as the location of the business ☐ B. CONTRACTOR bears the risk of loss related to the services provided under this Contract.

☐ C. CONTRACTOR provides services to two or more persons within a 12-month period or Contractor routinely engages in business advertising solicitation or other marketing efforts reasonably calculated to obtain new contracts for similar services.

☐ D. CONTRACTOR makes a significant financial investment in the business.

☐ E. CONTRACTOR has authority to hire additional persons to provide the services and has authority to fire such persons.

☐ F. NOT APPLICABLE – See section A.

Contractor Signature: __________________________________ Date: ____________ Title: ________________________________________________

SAMPLE