Florida Independent Contractor Analysis R.01/13

Independent Contractor Analysis R.01/13
Form RTS-6061
RTS-6061
R. 07/16
TC

Independent Contractor Analysis

Rule 73B-10.037
Florida Administrative Code
Effective Date 07/16

Information on this form is provided by:

Employing Unit/Business

Worker

Attach copies of any supporting documents (e.g., signed contract, agreements, employment applications, invoices,
prior IRS or state agency rulings on worker’s job class). In addition, complete a separate copy of this form for each job
title/class. If you do not know an answer, write ‘do not know’ or NA, if not applicable.
Employing unit/business: Answer all questions, including Section III if it is applicable. If you are completing this
form as required by Form DR-1, note that you do not need to submit this form if you have contracted with a distinct
business, occupation or profession that serves the general public, e.g., a plumber, general contractor, or certified
public accountant. Note: The issuance of a 1099 does not guarantee that a worker is an independent contractor and all
corporate officers who perform services are automatically deemed employees of their corporation pursuant to Section
443.036, Florida Statutes. Submit only one copy of this form per job-class and not for individuals.
Worker: Answer all questions, including Section III if applicable, but not Section IV.
Section I
1.	 Name, address, telephone and fax number(s) of the employing unit/business: ________________________________
	

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2.	 Type of work done by the employing unit/business: _______________________________________________________
	

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3.	 Name of the worker: __________________________________________________________________________________
4.	 Worker’s social security number*: _______________________________________________________________________
5.	 Worker’s job title or class:______________________________________________________________________________
6.	 If worker’s duties were not part of the employing unit’s regular business, how did they differ? __________________
	

_____________________________________________________________________________________________________

7. 	 Dates worker performed services for the employing unit/business: __________________________________________
8.	 Did the worker perform the majority of the services in Florida?

Yes

No

9.	 Was 1099-MISC or W-2 given to the worker?
Yes
No
	
If yes, attach copy.
•	 If worker was given both 1099-MISC and W-2, explain what changed and give dates for 1099-MISC vs
W-2 duties: ____________________________________________________________________________________
	

_______________________________________________________________________________________________

10.	 Briefly describe the worker’s job (add additional page if needed): ___________________________________________
	

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11.	 If the worker is still performing services, describe the working arrangements through the current date: __________
	

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12.	 List the skill(s) required to perform the work: _____________________________________________________________
	

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*Social security numbers (SSNs) are used by the Florida Department of Revenue as unique identifiers for the administration
of Florida’s taxes. SSNs obtained for tax administration purposes are confidential under sections 213.053 and 119.071,
Florida Statutes, and not subject to disclosure as public records. Collection of your SSN is authorized under state and
federal law. Visit our Internet site at www.floridarevenue.com and select “Privacy Notice” for more information regarding
the state and federal law governing the collection, use, or release of SSNs, including authorized exceptions.
www.floridarevenue.com

RTS-6061
R. 07/16
Page 2

Information on this form is provided by:

Employing Unit/Business

Worker

Section II
1.	 Did the worker perform services at the employing unit’s place of business?....................................... Yes	 No
2.	 Could the worker perform services for a competitor of the employing unit?........................................ Yes	 No
3.	 Did the worker use any of the employing unit’s equipment or tools?................................................... Yes	 No
4.	 Were the worker’s business or travel expenses reimbursed by the employing unit?............................ Yes	 No
		
A) Did employing unit provide a vehicle?....................................................................................... Yes	 No
		
B) Did employing unit pay for gas and maintenance?................................................................... Yes	 No
5.	 Did the worker receive any training from the employing unit?.............................................................. Yes	 No
		
A) If yes, was it mandatory?........................................................................................................... Yes	 No
		
B) Was training paid for by employing unit (if applicable)?............................................................ Yes	 No
6.	 Could the worker sub-contract the job or hire and pay others to do the work?................................... Yes	 No
7.	 Did the worker hire and/or supervise other workers who were paid by the employing unit?............... Yes	 No
8.	 Was there a written contract between the employing unit and the worker?......................................... Yes	 No
		
If yes, provide a signed copy.
9.	 Were there set hours of work? If yes, set by whom? ___________________________________ ............ Yes	 No
10.	 Did the employing unit give the worker instructions about:
		
A) When to do the work?................................................................................................................ Yes	 No
		
B) How to do the work?................................................................................................................. Yes	 No
		
C) Sequence in which the work was done?................................................................................... Yes	 No
	
D) Could the worker refuse assignments without penalty? ........................................................... Yes	 No
11. 	 Did employing unit provide a uniform, identification badge, business cards? (Circle all that apply)... Yes	 No
12.	 Could the worker provide services for the employing unit outside of the unit’s regular business hours?.. Yes	 No
13.	 Was the worker required to keep the employing unit informed of the progress of the work?.............. Yes	 No
14.	 Did the worker bill the employing unit for services performed? If yes, provide a copy........................ Yes	 No
15.	 Was the worker paid by time (hourly, weekly, or monthly), salary, commission, or by the job? (Circle all that apply)
16.	 Did the employing unit provide health or life insurance, vacation pay, holiday pay, sick pay, retirement benefits,
workers’ compensation coverage, bonuses? (Circle all that apply)
17.	 Was the worker supervised by an employee of the employing unit?.................................................... Yes	 No
18.	 Was the worker in business for himself/herself?................................................................................... Yes	 No
		
		

A) If yes, what is the business name? _______________________________________________________________
B) If yes, what is the worker’s federal employer identification number? _________________________________
C) If yes, did the worker have a financial investment in the business?.......................................... Yes	 No
		
D) If yes, did the worker advertise to the general public?.............................................................. Yes	 No
		
E) If yes, did the worker carry business liability insurance?........................................................... Yes	 No
		
F) Does the worker have a business tax receipt in this field? If yes, provide copy........................ Yes	 No
19.	 Could the worker quit or be discharged at any time without a breach of contract penalty?................ Yes	 No
20.	 Was the worker responsible for redoing defective work without additional compensation?................ Yes	 No
21.	 Do you believe the worker was an
employee or
independent contractor? Explain. (Attach additional page
if needed): NOTE: The Department’s website contains a list and description of the 10 factors used to determine
worker classification. __________________________________________________________________________________
	

______________________________________________________________________________________________________

22. What control, or right of control, did the employing unit have over how the work was to be performed? State any
examples of when this occurred. (Attach additional page if needed):__________________________________________
	

______________________________________________________________________________________________________

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RTS-6061
R. 07/16
Page 3

Section III - Salespersons Only
1.	 Did the worker:
		
A) Solicit orders for business supplies or merchandise for resale?...............................................
		
B) Sell consumer products/services directly to buyers on a commission only basis?..................
		
C) Perform services as an insurance or real estate agent?............................................................
		
If yes, provide license number _________________________________
D) Receive pay solely based on commission? .............................................................................
If no, was the worker paid by time (hourly, weekly, monthly, or salary)? (Circle all that apply)
2.	 Was the worker required to make a business investment other than travel expenses and
	transportation?........................................................................................................................................
3.	 Would the worker be penalized for not attending sales meetings?........................................................

Yes_

No

Yes_

No

Yes_

No

Yes

No

Yes_

No

Yes_

No

Section IV
To be completed ONLY by the employing unit/business. Attach additional sheets if needed.
1.	 Reemployment tax (RT)* account number of employing unit (if applicable): ___________________________________
2.	 Federal employer identification number: _________________________________________________________________
3.	 Type of employing unit:
Sole Proprietorship,
Partnership,
Corporation,
LLC (If LLC, do you file with
the IRS as a corporation?
Yes
No),
Non-profit (attach 501c3),
Agricultural,
Other (specify): ________
	

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4.	 Total number of workers in this job class considered independent contractors:_______________________________
5.	 Total number of workers in this job class considered employees:____________________________________________
6.	 If numbers were entered for 4 and 5, explain the difference between the independent contractors and the
employees: __________________________________________________________________________________________
	

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7.	 When did a worker in this job class first perform services of any kind for the employing unit/business? __________
	

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8.	 Do all workers in this job class who are considered independent contractors perform services under the same
terms and conditions?............................................................................................................................ Yes	 No
	
(Explain any differences):_______________________________________________________________________________
	
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* Formerly Unemployment Tax
Section V
Under penalties of perjury, I declare that I have read this completed questionnaire, including any attachments,
and the facts stated in it are true. I understand that knowingly providing false or misleading statements to the
Department of Revenue is punishable as a third-degree felony pursuant to section 443.071, Florida Statutes.
Employing Unit/Business Representative Signature: ___________________________________________________________
Print Name of Signer: ______________________________________________________________________________________
Title: _________________________________________
Date: ________________________________________ 	 Telephone Number: ________________________________________
-------------------------------------------------------------------------------------------------------------------------------------Worker Signature:______________________________ 	Title: _____________________________________________________
Date:_________________________________________ 	 Telephone Number:________________________________________