INDEPENDENT CONTRACTOR AGREEMENT (ICA)
SECTION ONE - INSTRUCTIONS FOR USE:
This ICA form may be used to pay or encumber funds for one-time nonrecurring or scheduled
payment contracts that are greater than $5000.00, exceed 45 days in length and completion
benchmarks have been agreed to and progress payments are to be made to individuals
engaged in technical, professional or specialized skills who:

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Provide one-time nonrecurring payment grater than $5000.00
Schedule progress payments (no limit).
Are being paid greater than $5,000.00 in total, (receipts required for travel
reimbursements), and
Are not otherwise employed by the Nevada System of Higher Education (which
includes CCSN, DRI, and GBC, TMCC, UNLV, UNR, WNCC, or any of the NSHE
System Administration Offices).
If the payment is $5,000 or less and travel expenses such as lodging or airfare have been
prepaid by the University by method of P-Card or Payment Voucher, DO NOT continue
processing this form. See instructions for the ISP contract.
SECTION TWO - Before the ICA contract is initiated: A Workers Classification form, W-9 (for
U.S. Citizens) or W8BEN (if International), and Insurance requirements, must be submitted to
the Accounts Payable department prior to the contract completion. Once the Worker has been
classified you will be notified of the classification and whether to proceed with the contact or not.
For questions regarding the proper use of this form or to determine ISP or ICA status, contact
the Assistant Controller for Accounts Payable at 895-1143.
Nonresident Aliens: If the individual is not a U.S. Citizen or lawful “permanent” resident (green
card holder), read the U.S. Tax Information for nonresident aliens information sheet, and contact
the Assistant Controller for Accounts Payable at 895-1143 before proceeding with this
document, additional documents may be required.
Hiring former NSHE employees: In an IRS audit, agents almost always examine whether an
employer wrongly classified employees as independent contractors. See information fact sheet
included in this package.
Insurance Requirements: The Contractor shall not commence work before proof of the
required insurance is evidenced by a certificate of insurance on an ACCORD 25 form, provided
by the Contractor’s insurance agent/broker or a notarized Affidavit of Rejection of Coverage for
Workers’ Compensation is received. By endorsement to all general and umbrella or excess
liability policies, the “Board of Regents, Nevada System of Higher Education” shall be named as
an additional insured for all liability arising from the contract. The Certificate of Insurance must
be filed with the contract so that it can be found in the event of a loss. Prior approval of the
insurance policies by NSHE shall be a condition precedent to any payment of consideration
under the contract.
SECTION THREE - Once you have received approval to proceed with the ICA contract:
Complete and submit the ICA contract, a flyer announcing the engagement, invitation letter or
complete the exhibits page included in this package. Submit the completed package to the
Controller’s Office, Accounts Payable mail stop 1053.
Negotiating the contract: It is recommended that the traveler makes his/her own travel
arrangements. When negotiating the contract payment totals, fees, expenses such as lodging,
airfare and meal costs should be estimated and be all inclusive of the entire contract amount.
Guidelines to consider: When negotiating the contract, determine if the payment will consist
of a fee as well as travel expenses; remember the total of the contract.
If meals and lodging are included in your contract negotiation, the daily allowance is $45.00;
(Breakfast $10.00; Lunch $15.00; Dinner $20.00) If any hosted meal is anticipated, the meal
allowance for that meal must not be considered in the allowance for that day.
Lodging may not exceed $150.00/night, including any taxes for stay during Sunday – Thursday,
and $175.00/night, including taxes for stay during Friday - Saturday. These rates may be
exceeded on a case-by-case basis, with proper approval of the President, Provost, Vice
President, Dean or Director.
Prepayment methods:

Lodging may be prepaid by P-Card; Lodging may also be prepaid by UNLV by
method of a payment voucher accompanied by the hotels confirmation of the
reservation.

Rental Vehicles are the responsibility of the contractor and may not be billed to a
university contracted agency.

Airfare may be prepaid by method of P-card or the Travel Authorization Form.
S:\Accounts Payable\Forms\Travel Authorization Form. PDF
Best Practice Example: Traveler to make own arrangements fee inclusive of travel expenses:
Total cost to the department and payable to the traveler = $6000.00 (no receipts required)
Example: Traveler with university prepaid arrangements: $6000.00 fee + $123.50 for five days
of meals (no receipts required), less one hosted lunch+ $550.00 for Airfare, prepaid by P-card, +
$450.00 for five days of lodging for out of state guest, prepaid by P-card:
Total department cost = $7,123.50 + hosted meal. Payable to Traveler = $6123.50
Example: Fee negotiated plus traveler to make own arrangements with travel to be reimbursed
after the engagement is complete:
$6000.00 fee + $123.50 for five days of meals, less one hosted lunch+ $550.00 for Airfare,
prepaid by traveler, + $450.00 for five days of lodging for out of state guest, prepaid by traveler:
Total department cost = $7,123.50 + hosted meal. Due to Traveler = $7123.50 with acceptable
paid receipts including hotel folio, proof of airfare cost, meal receipts (will be reimbursed at a
maximum of $45.00 per day), and any additional expenses.
Scheduled Payments: Payments to ICA will be processed against the encumbered contract
when invoiced by the department or contractor. If travel expenses are to be reimbursed, all
required receipts must be attached to the payment request form.
Please call 895.1143 for your department’s assigned ISP numbers.
DO NOT SEND INFORMATION PAGES TO THE CONTRACTOR; KEEP IT FOR YOUR
REFERENCE. SEND ONLY APPLICABLE PAGES AND FAX SIGNATURES ARE
ACCEPTED.
Hiring Independent Contractors who are Former NSHE Employees
The purpose of this announcement is to clarify NSHE and UNLV policies and procedures on
hiring independent contractors.
Individual departments negotiate and draft contracts with independent contractors. Once an
independent contractor agreement (ICA) or an Independent Service Provider contract (ISP) form
is completed, it is submitted to the Accounts Payable Department for review and approval.
Hiring departments are required to provide complete information and forms, including additional
supporting documents on independent contractors and guest speakers who are not U.S. citizens
or legal permanent residents. If it is concluded that the individual does not qualify as an
independent contractor, the independent contractor agreement is returned to the initiating
department with a notification. Payments cannot be processed based on incomplete or improper
forms.
The University strictly adheres to the IRS guidelines and "common law" tests in determining
whether a service provider qualifies as an independent contractor or as a University employee.
The determination criteria are provided in the Accounts Payable web page,
http://www.unlv.edu/accounts payable/html.
To ensure our conformity with NSHE policy and the federal regulations, individuals should be
hired as LOA’s when one of the following conditions is met:
1. The individual is currently maintaining a position with NSHE, which is comprised
of the Community College of Southern Nevada, Desert Research Institute, Great Basin
College, Nevada State College at Henderson, Truckee Meadows Community College,
UNLV, UNR, Western Nevada Community College, or NSHE System Administration
Offices.
2.
The individual formerly maintained a position with NSHE, during the
previous calendar year prior to the contract start date. However, when a former
employee has moved out of state and provides service, this restriction does not apply.
In an IRS audit, agents almost always examine whether an employer wrongly classified
employees as independent contractors. If the IRS discovers any failure to comply with federal
rules and regulations, both the University and the individuals are subject to substantial financial
penalty. When the compliance failure is due to the incorrect and/or incomplete information
provided to the Accounts Payable Department by the department and/or by the independent
contractor, the responsible department will be required to absorb these costs.
U.S. TAX INFORMATION FOR NONRESIDENT ALIEN INFORMATION SHEET
The Internal Revenue Service (IRS), the U.S. government tax authority, has issued strict regulations regarding the
taxation and reporting of payments made to non-United States citizens. As a result, the University and Nevada
System of Higher Education (“NSHE”) may required to withhold U.S. income tax and file reports with the IRS in
connection with payments made by the NSHE to consultants and guest speakers who are not U.S. citizens or
permanent resident aliens (greencard holders) and who receive compensation for services performed and/or
reimbursement for travel.
The NSHE must determine whether you will be treated as a “resident alien” or “nonresident alien” for U.S. tax
purposes. Consultants or guest speakers who enter the U.S. under a visitor’s visa (e.g., B-1 or B-2) or a waiver of a
visa (e.g., WB or WT) are generally treated as nonresident aliens if they are present in the U.S. for a total of less
than six months over a three year period. Consultants or guest speakers who are present in the U.S. under a J-1 visa
are usually considered nonresident aliens for the first two calendar years that they are present in the U.S.
The NSHE is generally required to withhold taxes for all payments made to nonresident aliens. In order for the
NSHE to make a correct determination about tax withholding, all guest speakers who are not citizens or permanent
resident aliens of the U.S. must complete the Alien Information Collection Form and return it to the NSHE
department that issued the initiation to speak. Once your U.S. tax status has been determined, if you are a
nonresident alien, a tax equal to 30 percent is generally required to be withheld. Taxable items include, but are not
limited to:
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Honoraria
Consulting Fee
Compensation
Speaker Fee
Living Allowance
Cash Award
The U.S. maintains income tax treaties with over 50 countries, and certain taxable payments made by the NSHE to
you may be exempt from U.S. tax based on an income tax treaty entered into between the U.S. and your home
county. The existence of a tax treaty does not automatically ensure an exemption from taxation; rather, you must
satisfy the requirements for the exemption set forth in the tax treaty. In order to be considered for a tax treaty
exemption, you must complete Form 8233. You must complete Form 8233 and return it via facsimile or post to the
NSHE department that invited you to speak. A 30 percent withholding tax will be deducted from compensation
payments made to consultants or guest speakers (i) who are from countries that do not maintain an income
tax treaty with the U.S., (ii) whose payment does not qualify for exemption under a tax treaty, or (iii) who
does not complete From 8233 in a timely manner.
If From 8233 is submitted after the NSHE has deducted tax from a payment to you, the NSHE cannot refund the tax
to you; you must file a U.S. income tax return at year-end to apply for a refund of tax withheld from the IRS. Please
note that the NSHE is also required by law to report to the IRS all payments made to a nonresident alien, or a third
party on his or her behalf, regardless of whether the payment is subject to U.S. tax.
All individuals who receive payment from the NSHE are also required by law to disclose their U.S. social security
or individual taxpayer identification number, he or she is required to complete From W-7 and submit the form and
supporting documentation in person to the Assistant Controller for the Accounts Payable Department.
______________________________________________________________________________
All consultants and guest speakers who are not citizens or permanent resident aliens of the U.S. are required to
complete tax information forms prior to receiving any payment. If you have additional questions about how to
complete the required forms or need information concerning tax-withholding obligations, please contact the
Assistant Controller for the Accounts Payable Department at 702.895.1143
SECTION TWO:
Worker Classification Questionnaire
Name of Worker ____________________________________________________
Dba (name of business):
____________________________________________________________
Address:
____________________________________________________________
Social Security Number:________________________
EIN# (if applicable):____________________
Department:
_________________________MS_______Phone________Fax_________
Questionnaire completed by: ____________________________________(Dept. or Worker
may complete)
NOTE: ALL QUESTIONS MUST BE COMPLETED. ANY ANSWER WITH UNKNOWN OR N/A WILL CAUSE THE FORM TO BE
REJECTED.
Instructions & Training
1.
Please describe the services below to be performed and provide worker’s job title.
2.
Describe the worker’s business/firm.
3.
List all the specific details that will be given to the worker about the services to be
performed. Include: 1). How does the worker receive work assignments? 2). Who
determines the methods by which assignments are performed? 3). What
routines/patterns will be followed? 4). What order/sequence will be followed?
4.
What types of reports are required from the worker? (Attach examples if applicable).
5.
Describe the worker’s daily routine (i.e., schedule, hours, etc.)
6.
Who will decide where to purchase supplies or services necessary for the job?
7.
How many assistants will the worker hire to assist him/her with the job, and will UNLV or
the worker pay the assistants?
Financial Control
8.
List any significant investment that the worker has in their business relative to his/her
Industry.
9.
List the tools or equipment, and expenses (all resources) that UNLV and the worker will
use to perform the service(s) including where the work will be performed.
UNLV Provides: (include office space, computer, etc. if applicable)
Worker Provides:
10.
What economic loss or financial risk, if any, can the worker incur beyond the normal loss
of salary?
11.
Describe how the worker advertises their services to the public (yellow pages, word of
mouth, etc).
12.
List clients/customers that the worker provides these services for (provide address,
phone if applicable)
13.
What is the method of payment to this worker (hourly, monthly, shift, flat fee, invoiced as
work progresses)? And what is the estimated cost of service to be paid to the worker?
14.
Does worker have their own workman’s comp coverage through their firm should they
become injured while providing services? And what is the risk of injury that the worker
may sustain for the projected service(s) to be performed? Attach insurance coverage
documentation.
15.
Does the individual have a business license and insurance? Please attach copy of
business license & insurance info. (Payments may be able to be processed off a
purchase order – call for more details).
Relationship of the Parties
16.
Is there a written agreement/contract between UNLV and the worker? (If yes, please
attach).
17.
List any benefits that UNLV will provide to the worker (insurance, education, travel,
other).
18.
How much notice will be given to UNLV should the worker decide to terminate this
arrangement?
19.
How much notice will be given to the worker should UNLV decide to terminate this
arrangement?
20.
What sort of situations would require the dismissal of the worker?
21.
Estimate the worker’s time on UNLV campus providing services for this job.
22.
How long is the service for this job expected to last? (If indefinitely, explain).
23.
List the departments here on campus that may require the same services, and/or if the
worker is already providing services to other departments.
24.
List the special skills/training that the worker possesses.
Fax to 702.895.1519 or email to Yvette.Walton@unlv.edu:
1)
2)
3)
THE WORKER CLASSIFICATION FORM
W-9 OR W-8BEN AND:
INSURANCE REQUIREMENTS OR AFFIDAVIT OF REJECTION OF COVERAGE OF
WORKERS’ COMPENSATION
Do not continue until you have received approval and notification of the vendor number by
email.
______________________________
Approved
__________
Date
Enter your TIN in the appropriate box. The TIN provided must match the name given on Line 1 to avoid backup withholding. For individuals, this is
your social security number (SSN). However, for a resident alien, sole proprietor, or disregarded entity, see the Part I instructions on page 3. For
other entities, it is your employer identification number (EIN). If you do not have a number, see How to get a TIN on page 3.
or
Under penalties of perjury, I certify that:
1
The number shown on this form is my correct taxpayer identification number (or I am waiting for a number to be issued to me), and
2
I am not subject to backup withholding because: (a) I am exempt from backup withholding, or (b) I have not been notified by the Internal
Revenue Service (IRS) that I am subject to backup withholding as a result of a failure to report all interest or dividends, or (c) the IRS has notified
me that I am no longer subject to backup withholding, and
3
I am a U.S. citizen or other U.S. person (defined below).
Certification instructions. You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup
withholding because you have failed to report all interest and dividends on your tax return. For real estate transactions, item 2 does not apply. For
mortgage interest paid, acquisition or abandonment of secured property, cancellation of debt, contributions to an individual retirement arrangement
(IRA), and generally, payments other than interest and dividends, you are not required to sign the Certification, but you must provide your correct
TIN. See the instructions on page 4.
Sign
Here
Signature of
U.S. person
Date
General Instructions
Section references are to the Internal Revenue Code unless
otherwise noted.
Purpose of Form
A person who is required to file an information return with the IRS
must obtain your correct taxpayer identification number (TIN) to
report, for example, income paid to you, real estate transactions,
mortgage interest you paid, acquisition or abandonment of secured
property, cancellation of debt, or contributions you made to an IRA.
Definition of a U.S. person. For federal tax purposes, you are
considered a U.S. person if you are:
•
An individual who is a U.S. citizen or U.S. resident alien,
•
A partnership, corporation, company, or association
created or organized in the United States or under the laws of the
United States,
•
An estate (other than a foreign estate), or
•
A domestic trust (as defined in Regulations section
301.7701-7).
Payments are subject to1099
Use Form W-9 only if you are a U.S. person (including a
resident alien), to provide your correct TIN to the person
alien) reporting guidelines.
requesting it (the requester) and, when applicable, to:
1. Certify that the TIN you are giving is correct (or you are
waiting for a number to be issued),
2. Certify that you are not subject to backup withholding, or
3. Claim exemption from backup withholding if you are a U.S.
exempt payee. If applicable, you are also certifying that as a
U.S. person, your allocable share of any partnership income from a
U.S. trade or business is not subject to the withholding tax on
foreign partners’ share of effectively connected income.
Note. If a requester gives you a form other than Form W-9 to
request your TIN, you must use the requester’s form if it is
substantially similar to this Form W-9.
or 1042-S (if a nonresident
Insurance Requirements
High risk activities involving aircraft, boats, and chartered buses will require higher limits than discussed below. Contact the
Risk Management Office for insurance requirements. The Contractor shall, at Contractor’s sole expense, procure, maintain and
keep in force for the duration of the Contract the following conforming to the minimum requirements specified as follows:
1.
Worker’ Compensation and Employer’s Liability Insurance
a. Does the Contractor have employees?
Yes
No
If the answer to question a. is yes, the Contractor shall provide proof of
Worker’s compensation insurance as required by NRS 616B.627 or proof
that compliance with the provisions of Nevada Revised Statutes, Chapters
616A-D and all other related Chapters, is not required.
b.
Nevada law allows the following to reject workers’ compensation
Coverage if they do not use employees or subcontractors in the
performance of work under the contract. Indicate the appropriate
Category below:
Individuals/Sole proprietors (NRS 616B and NRS 617.210)
Unpaid officers of quasi-public, private, or nonprofit corporations
(NRS 616B.624 and 617.207)
Unpaid managers of LLC’s (NRS616B.624 and NRS 617.207)
An officer or manager of a corporation or LLC who owns the
Corporation or LLC (NRS 616B.624 and M+NRS 617.207)
If the Contractor has rejected workers’ compensation coverage under
Nevada law, the Contractor must indicate the basis for the rejection
of coverage above; and complete, sign, and have notarized an Affidavit
of Rejection of Coverage. The affidavit form can be found in this
package.
2.
Commercial General Liability (Minimum Limits)
a. Does the Contractor have a Commercial General Liability Policy?
Yes
No
Yes
No
Yes
No
If the answer to question a. is yes, the Contractor shall provide a Certificate of
Insurance for Commercial General Liability with the following minimum limits:
Each Occurrence
Products/Completed Operations Aggregate
Personal and Advertising Injury
General Aggregate
$1,000.000
$1,000.000
$1,000.000
$1,000.000
If the answer to question a. is no; or if the Contractor limits do not meet the
requirement shown above, contact the Risk Management Office.
3.
Business Auto Liability Insurance
a. Will the Contractor drive onto NSHE property and/or transport NSHE
employees or students?
If the answer to question a is no, evidence of business auto liability insurance
is not required.
b.
Does the Contractor have a Business Auto Liability policy?
If the answer to questions a & b is yes, the Contractor shall provide a Certificate
of Insurance for Business Auto Liability with the following minimum limits for
owned, Non-Owned or Hired Automobiles:
Per Accident, Combined Single Limit
$1,000.000
If the answer to question b is no, contact the Risk Management Office
SECTION THREE
________________
ICA#
____________________
Vendor #
INDEPENDENT CONTRACTOR AGREEMENT (ICA)
Payment Information
All information is required (Fill in all blanks, omitting any information may delay processing):
Service Provider Payment Information:
FULL NAME ______________________________
Last Name (Please Print or Type)
_____
______________________________________
MI
First Name
U.S. TIN/Social Security Number ____________________________________________________
Payee must complete Form W-9 (if a U.S. Citizen) or W-8BEN (if International
Engagement Date(s) _________________________ to ______________________________
Total Payment Amount $ ___________________________________________
Scheduled Payments
#1
#2
#3
#4
#5
#6
Yes
(If Yes list payments)
No
(Note: payment will be made after the last engagement date)
$_______________
$_______________
$_______________
$_______________
$_______________
$_______________
#7
#8
#9
#10
#11
#12
$________________
$________________
$________________
$________________
$________________
$________________
Mailing Address (number)____________________________________________________________________
(PO Boxes are not accepted)
City_______________________________State__________________________Zip___________________
A)
Is the payee a current or former (within the current calendar year) employee of any institution of the Nevada
System of Higher Education?
If the answer to question A is yes, do not proceed with this form. Process the payment on an employment
document.
Yes
No
B) Is the payee a member of the same household as a NSHE employee?
If the answer to question B is yes, do not proceed with this form. Under the Board of Regents “Conflict of
Interest” policy (BOR Handbook, Title 4, Chapter 10), payment is not allowed.
Yes
No
C) Is the payee a U.S. citizen or lawful permanent resident (green card holder)?
If the answer to question C is no, contact the Assistant Controller for A/P. “See information regarding U.S.
tax information for Nonresident Alien Consultants and Guest Speakers, complete NRA collection
information.
Yes
No
ACCOUNT INFORMATION:
FUND
AGCY
ORGN
OBJT
SOBJ
AMOUNT
TOTAL
Disposition of check if not to be mailed to the payee’s
address:
The Nevada System of Higher Education is an equal opportunity/affirmative action employer and
does not discriminate on the basis of race, color, religion, sex, age, creed, national origin, veteran
status, or physical or mental disability in any program or activity it operates. The NSHE employs
only United States citizens and individuals lawfully authorized to work in the U.S.
Payee must complete and attached Form W-9 (if a U.S. citizen/resident) or W-8BEN (if international)
PAYMENT AUTHORIZATION: Based on the above,
AGREEMENT: I have read and agree to the
It is my determination that the payee meets
the guideline and requirements of this contract.
above representations and assert that they are
true and correct.
_________________________________
Authorized Accounts Signature
__________
Date
_________________________________
Printed Name of Authorized Signer
_________________________________
Department
___________________________
Payee Signature
________
Date
________________________________________
Mailing Address (PO Boxes are not accepted)
__________
Mail Stop
________________________________________
City
State
Zip
_________________________________
Department Contact
_____________________
Phone Number
_____________________________
Telephone Number
________________________________________
e-mail address
_____________________
Fax Number
CONTROLLERS OFFICE REVIEW
By:____________________Date:_________
________________
Fax Number
Contract Exhibits A, B and C.
ICA # ________________
Exhibit A. Explain in detail what the contractor will do specifically what will be done by the contractor, where the work will be
accomplished, and when the work will be completed).
Exhibit B. Indicate the total amount of payment and the date when the payment will be made. The date the payment will be made
should be the ending date of this contract. If this contract exceeds 45 days in length and completion benchmarks have been
agreed to and progress payments are to be made, indicate each benchmark and its associated progress payment dollar amount.
Exhibit C. List any special conditions that apply.
PAYMENT REQUEST FOR ICA CONTRACT #_______________
_________________________________
___________________________
VENDOR NUMBER:
Date Prepared:
_________________________________
___________________________
NAME:
_______________________________________
ADDRESS
_______________________________________
Need Check by:
Prepared By:
________________________________
Telephone Number
______________ __________________
Department & Mail Sort Code
Scheduled Payment Due $_____________________
Period Covered __________-__________
Travel Expenses
(Must be submitted with original receipts, copies will not be acceptable and will delay or reduce payment):
Receipts Attached
Yes
Airfare
$_____________________
Lodging
$_____________________
No
Ground Transportation $_____________________
Meals
$_____________________
(Maximum allowed $26.00 per day)
Fuel
$_____________________
Parking
$_____________________
Other:
$_____________________
Total Due ICA
$_____________________
Approved
Date
Approved
Date