University Physicians & Surgeons, Inc.
NONEMPLOYEE COMPENSATION/INDEPENDENT CONTRACT AGREEMENT

                 This form must accompany each request for payment to an individual for honorariums, fees, lectures, awards, or any other fixed and determinable sums which qualify under the Internal Revenue Service’s definition of nonemployee compensation. 

Text Box: TO BE COMPLETED BY INDIVIDUAL RECEIVING PAYMENT

 

Name                       ______________________________________________________________________________________________

 

Home Address  __________________________________________________________________________________________________
(Street Address)

 
_______________________________________________________________________________________________________________
 (City, State, & Zip Code)

 

Soc. Sec. Num. ______________________ Telephone#(  )_________________________

For purposes of assuring the correct information return is filed with the IRS regarding this payment, please check one of the following:

 ____  1.  I am a citizen or national of the United States.

 ____  2.  I am an alien lawfully admitted for permanent residence (Alien Number______________).

 ____  3.  I am an alien authorized by the immigration and Naturalization Service to work in the United States (Alien number____________ or Admission number_____________, expiration of employment authorization, if any_______________).

 I hereby certify that my name, home address and Social Security number are as they appear on the tax information returns I file with the Internal Revenue Service and that I am a citizen of the United States of America or an authorized alien eligible to work in the United States.  I understand this compensation will be paid to me in full and no federal, state, OASDI or Medicare taxes, Worker’s Compensation or Unemployment Insurance, or other employee-related benefits will be withheld.  Further, I understand that University Physicians & Surgeons, Inc. will file the appropriate information return with the Internal Revenue Service and that I am responsible for reporting this as income on my tax returns.

 __________________________________________________                            __________________

                Signature of recipient                                                              Date

Text Box: TO BE COMPLETED BY UP&S DEPARTMENT

 

The purpose of this nonemployee compensation in the amount of $__________________ is as follows: (Please provide a brief explanation.)

 __________________________________________________________________________________________________________________________


___________________________________________________________________________________________________________________________

  

I hereby certify that the purpose for which this nonemployee compensation is being paid has been fulfilled and is now due and payable as agreed upon.

  

____________________________________________________                                        _____________________

                Department Signature                                                                                             Date