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110-23 Master Contract No.900973,Procurement Contract No.7485 <br /> 4. Is the relationship between the County and the contractor intended ( ) ( ) <br /> to be ongoing? <br /> III. FOR CONSULTANTS, PROJECT MANAGERS,PROJECT YES NO <br /> COORDINATORS <br /> 1. Is the contractor being hired for a period of time rather than for a ( ) ( ) <br /> specific project? <br /> 2. Will payment be based on a wage or salary (as opposed to a ( ) ( ) <br /> commission or lump sum)? <br /> IV. FOR PHYSICIANS, PSYCHIATRISTS, DENTISTS, YES NO <br /> PSYCHOLOGISTS <br /> 1. Will the agreement be with an individual who does not have an ( ) ( ) <br /> outside practice? <br /> 2. Will the contractor work more than an average of ten hours per ( ) ( ) <br /> week? <br /> IF THE ANSWER TO QUESTION 2 IS YES, ANSWER <br /> QUESTION 3. <br /> 3. Will the County provide more than 20% of the contractor's ( ) ( ) <br /> income? <br /> 4. If the answer to either question 2, or if required, question 3 is NO, <br /> the entire answer is NO. <br /> A "YES" answer to any of the questions in Section II, or, if applicable, Sections III or IV <br /> constitutes justification for paying the contractor through the payroll system as an <br /> "employee for withholding purposes." <br /> CERTIFICATIONS: <br /> I hereby certify that the answers to the above questions accurately reflect the anticipated <br /> workin el ' niPip for this contract. <br /> j �/U � e <br /> Contractor S' nature 1 Agency/Deepartment Head/Designee <br /> n / filik (� Q/ Signature — <br /> 1Jet,tir'e � ,�, h � y 07 / �'c2SQn, d.J Gl/7/�qrr 1 f�f�7,�c <br /> Printed Name / Printed Name <br /> S/7/fl Oh_ <br /> Date Date <br /> Approved <br /> Page 2 of 2 <br />