8F Consent 2011 0906 - Laserfiche WebLink

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110 -23 Contract No. QUESTIONNAIRE FOR DETERMINING THE WITHHOLDING STATUS INSTRUCTIONS: This questionnaire is to be completed by the County department for services contracts and must be included as part of the contract package. Be sure to answer all of the questions in Sections I and II and to complete the certifications on page 2. Sections III and IV contain supplemental questions to be answered for contractors in certain service categories. CONTRACTOR NAME: City of San Leandro DEPT #: TITLE /SERVICE: Health and Wellness Services for San Leandro Seniors DEPT. CONTACT: Jennifer Chan PHONE: (510) 618 -2016 I. INFORMATION ABOUT THE CONTRACTOR YES NO 1. Is the contractor a corporation or partnership? (X ) ( ) 2. Does the contractor have the right per the contract to hire others to (X) ( ) do the work agreed to in the contract? 3. If the answer to BOTH questions is YES, provide the employer ID number here: 94- 6000421. No other questions need to be answered. Withholding is not required. 4. If the answer to question 1 is NO and 2 is YES, provide the individual social security number here: No other questions need to be answered. Withholding is not required. 5. If the answer to question 2 is NO, continue to Section II. II. RELATIONSHIP OF THE PARTIES YES NO 1. Does the County have the right to control the way in which the work ( ) ( ) will be done, i.e., will the County be able to specify the sequence of steps or the processes to be followed if it chooses to do so? 2. Is the contractor restricted from performing similar services for other ( ) ( ) businesses while he is working for the County? 3. Will the contractor be working for more than 50% of the time for the ( ) ( ) County (50% = 20 hrs /wk; 80 hrs /mo)? 4. Is the relationship between the County and the contractor intended to ( ) ( ) be ongoing? Page 1 of 2