STATE OF SOUTH DAKOTA ) ) SS AFFIDAVIT OF EXEMPT STATUS COUNTY OF ) I state under oath as follows: 1.I, , operating as ,(Independent Contractor) (Independent CBusiness Name) have agreed to provide services for during calendar year . (General Contractor) (Year) 2.I have read, signed, and attached the Exempt Status Fact Sheet and understand that an IndependentContractor is one who engages to perform certain services for another, according to his own mannerand method, free from control and direction of the contractor in all matters connected with theperformance of the service, except as to the result or product of the work.3.I understand that based upon the representations in this Affidavit of Exempt Status that I have signed, Iam requesting that the Contractor identified above consider my business to be that of an independentcontractor; that I am not an on Act and the policy issued by.(General 4.I am an independent contractor, not an employee of the contractor, and I do not want workcompensation insurance.5.6.I have read, signed, and attached the Exempt Status Fact Sheet describing what an IndependentContractor is and the information provided is not the result of force, threats, coercion, compulsion, orduress.7.I understand that the execution of this affidavit shall establish a rebuttable presumption that I am not anemployee for 8.I understand that by signing this affidavit I will not be eligible for compensation under the South Dakota Compensation Law.9.I understand the execution of this affidavit does not affect the rights or coverage of any employee of theindividual executing the affidavit.10.I understand that soliciting or providing false information on this affidavit with actual knowledge is aClass 2 misdemeanor. Independent Contractor Signature Date General Contractor Signature Date Independent Contractor Name General Contractor Name Title Title Subscribed and sworn to before me Subscribed and sworn to before me this day of , 20. this day of , 20. Notary Public-South Dakota Notary Public-South Dakota My commission expires: . My commission expires: . (Seal) (Seal) See SDCL 62-1-20 and ARSD Ch. 47:03:10 American LegalNet, Inc. www.FormsWorkFlow.com INDEPENDENT CONTRACTOR EXEMPT STATUS FACT SHEET An independent contractor is defined by law as one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work. Below are statements to help you decide if you are an independent contractor. No one statement is controlling, and your status is based on all the facts in your situation. 1.The nature of the contract between you and the contractor shows you are independent from the contractor. Forexample: Is there a written contract where you agree that you are an independent contractor? Do you maintaincommercial general liability insurance or other business insurance? 2.The contractor exercises no control over the details of your work or independence. Do you exercise control overthe details of the work? Do you create plans or specifications for the job? Do you set your own work hours? 3.You are engaged in a distinct occupation or business for others. Do you work for a company or individual otherthan the Contractor? Do you work for a competitor of the Contractor? Does your business have a logo or uniform? 4. 5.You cannot complete the affidavit if you are a subcontractor who is also an employer. Do you have employees? 6.Is your business incorporated? If you do business as a corporate entity you are typically considered an employeeof the corporation and cannot complete the affidavit. 7.Your job is the kind of occupation where the work is usually performed by a specialist without supervision, and notunder the direction of the contractor. 8.Your occupation requires special skills, license, education, or training. 9.The contractor does not supply the things needed to perform your job such as the tools and the place of work. Dobusiness location or jobsite? 10.The length of the job and how long you have worked for the Contractor does not show that you are really anemployee. For example: Is this a one-time job, or will you be doing this for the contractor regularly? 11.You are paid as a separate contractor, not as an employee. Do you invoice the Contractor for your services? Doyou file a federal income tax return for your business? Do you expect to receive an IRS Form 1099 from theContractor? 12.Your work is not the regular business of the Contractor. 13.You do not have the right to terminate the relationship without liability. For example: If you quit before the job isfinished, is there a penalty? Based upon these factors, do you believe that you are an independent contractor with exempt status? (check appropriate answer) ()YES () NO Signature (INDEPENDENT CONTRACTOR/EXECUTOR) Note: An employer who knowingly solicits or requires an employee or subcontractor to execute an affidavit when the policy is guilty of a Class 2 misdemeanor. See SDCL 62-1-20 and ARSD Ch. 47:03:10 American LegalNet, Inc. www.FormsWorkFlow.com