Sample Exhibit 3 - Certification Statement for Corporation or Independent Contractor.pdf
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- Attached to
- Medical Examiner Body Removal Services
- Solicitation number
- RFP-71-2024
- Issued by
- Multnomah County, Oregon
About this file
This document is a Certification Statement for Corporation or Independent Contractor for a Multnomah County Contract, specifically designed for potential contractors providing services to the Multnomah County Health Department's Medical Examiner's Office in Oregon. The form is a standardized template that requires contractors to certify their business status and independent contractor qualifications, with two primary sections: Section A for corporate entities and Section B for sole proprietors working as independent contractors.
The certification requires contractors to verify their legal business structure, registration status for specific services (such as construction or architectural services), and ability to independently provide services. In Section B, contractors must confirm at least three criteria demonstrating their independent contractor status, such as having a separate business location, bearing service-related financial risks, providing services to multiple clients, making significant financial investments in the business, or having the authority to hire and fire additional personnel. The document is dated May 2, 2022, and is marked as a sample form, indicating it is a template for potential contractors interested in providing decedent transportation services for the Multnomah County Medical Examiner's Office.
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Text version
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
| MULTNOMAH COUNTY CONTRACT |
| A. CONTRACTOR IS A CORPORATION, LIMITED LIABILITY COMPANY, OR A PARTNERSHIP. |
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