SD EForm - 1658 V3 Use this form to apply to the department for certification as an independent contractor as permitted by SDCL 62-110, SDCL 62-1-11, SDCL 62-1-12, and ARSD chapter 47:03:07. Answer each question completely. A question may be answered by "N/A" (not applicable), if appropriate. If more space is needed, use additional pages, clearly identifying your response to the applicable question number. Any supporting document or documents should be attached to this application. If you have any questions about this application or the information requested, please call (605) 773-3682. 1) Applicant's name: (Applicant must be an individual. Do not use a business, partnership or corporate name) Applicant's mailing address: Applicant's telephone number: 2) Does the applicant own a vehicle licensed and registered as a truck, road tractor, or truck tractor? Yes No If the answer to #2 is yes, please identify the licensing and registering governmental agencies, or registration numbers: any license 3) Name any and all person(s) or firm(s) with whom the applicant contracts to provide trucking services. (Such person or firm will be referred to in this application as "contractee".) Independent Contractor Verification Application rev. June 2004 American LegalNet, Inc. www.FormsWorkFlow.com 4) Is the applicant responsible for maintenance of the vehicle? If "No", please explain: Yes No 5) The applicant is responsible for the following vehicle costs while on the road: Fuel, Repairs, Supplies, Collision Insurance, Personal expenses Other (please indicate): 6) Does the contractee allow the applicant to draw advances against compensation? Yes No If "Yes", how does the applicant repay such draws or advances? 7) Is the applicant responsible for supplying the necessary driver(s) to operate the vehicle? Yes No a) If the applicant has any helpers, are such helpers considered the applicant's employees? Yes No b) Does the contractee have to hire or approve them? Yes No c) Is the applicant responsible for providing proof of workers' compensation insurance for any and all of applicant's employees? Yes No 8) How is the applicant paid by the contractee? Other (please indicate): salary, commission, hourly wage, mileage or load, 9) Does the contractee report the applicant's income to the Internal Revenue Service? Yes No If "Yes", how is that income reported? 1099, W-2, Other (please indicate): 10) Does the contractee carry workers' compensation insurance on the applicant? Yes No 11) Does the contractee pay unemployment insurance taxes on behalf of the applicant? Yes No 12) Does the contractee train the applicant? If "Yes", please explain: Yes No. 13) Does the applicant direct the details and means of the way the work is done, within regulatory requirements, operating procedures of the contractee, and specifications of the shipper? Yes No. If "No", Please explain, including any directions specified by the contractee: American LegalNet, Inc. www.FormsWorkFlow.com Please send a completed copy of this application to: and Regulation The applicant, by its authorized representative: Authorizes the department to audit or investigate the accuracy of any statement made in this application and related documents; Agrees to assist the department in conducting the audit or investigation; and Agrees to allow the department access to its place of business and to information and record requested by the department. The applicant understands and agrees that if a material fact in this application or related documents has been misrepresented or if the applicant no longer meets the requirements of the law and administrative rules, the department may deny or may suspend or revoke the independent contractor certification of the applicant under ARSD 47:03:07:04. Applicant name (please print): ____________________________________ Applicant signature: ____________________________________________ Date signed: _________________________________________ American LegalNet, Inc. www.FormsWorkFlow.com