SAMPLE
NEW YORK UNIVERSITY
Form IND4000
For Accounts Payable Use Only
PAYMENT TO INDIVIDUALS
(LAST REVISED APRIL 16, 2002)
Use this form to arrange for payment and/or reimbursement to individuals with Social Security Number (or ITIN
if non-resident aliens) who are not NYU employees or students.
PAYEE INFORMATION
For Accounts Payable Use Only
1. RESIDENCY STATUS
Is the Payee or beneficiary of this payment a U.S. Citizen or Permanent Resident?
U
✘ YES
U
NO
COUNTRY
CODE
COUNTRY
If NO, you must attach an Alien Information Collection Form and other required tax forms. Refer to the Manual on
Payments Made to Nonresident Aliens for more information. This manual can be obtained from the Controller’s
Division Web site: www.nyu.edu/cdv.
INCOME CODE
Note: If payment is to a nonresident whose country of origin has no tax treaty with the U.S., NYU will withhold
applicable taxes from the amount.
2. TYPE OF PAYMENT (Check appropriate box)
U
U
U
U
(a)
(b)
(c)
(d)
Minor services with total payments (exclusive of reimbursement of incidental expenses) up to $600.00 in calendar year
Honorariums, royalties or awards (can include incidental expenses)
Reimbursement to prospective employee, student, or volunteer
Professional Services (can include incidental expenses)
U
U
✘
i. Total payments up to $3,000.00 in calendar year
ii. Total payments over $3,000.00 in calendar year (If this box is marked, Form IND4000A must be completed and attached.)
3. PAYEE’S SOCIAL SECURITY NUMBER OR ITIN
For Accounts Payable Use Only
001-99-5678
VENDOR NUMBER:
4. PAYEE’S FULL NAME (FIRST, MIDDLE INITIAL, LAST)
Maria T. Jones
8. ENCLOSURE TO BE MAILED WITH CHECK
5. HOME ADDRESS (REQUIRED)
U YES (EXTRA COPY ATTACHED)
1578 Main Street
San Diego, CA 87621
U YES
9. HOLD FOR PICK-UP?
(For extraordinary circumstances only. Print
full name and telephone number)
6. ALTERNATE MAILING ADDRESS (IF APPLICABLE)
7. DEPARTMENT TO BE CHARGED
CIMS
EXPENSE/ACCOUNT DETAILS
10. INVOICE NUMBER
11. INVOICE
OR DESCRIPTION
DATE OR DEPT
12. AMOUNT
(Up to12 characters) PROCESS DATE
04
04 | 22 | 02
|
22
|
|
|
|
|
ACCOUNT
02 $ 3500
CONSULT
REIMBU
TOTAL AMOUNT
For Accounts Payable
Use Only
13. CHARTFIELD
125
ORG/DEPT
FUND
PROGRAM
6 | 0 | 4 | 5 | 5 2| 5 7| 4 | 2 | 0 | 0
6| 5 | 5 | 3 | 0 2 | 5 7 | 4 | 2 | 0 | 0
00
60
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
| | | |
|
| | | |
|
14. TOTAL AMOUNT REQUESTED (IN WORDS)
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Net
1099/
Amount 1042S
F | 5| 0 | 8 | 0
F 5 0 8 0
| | | |
|
|
3625
60
$__________
Tax
Rate
PROJECT
Three-thousand, six-hundred and twenty-five
60
15. DESCRIBE FULLY THE NATURE OF THE PAYMENT (Description will not appear on the check)
Collaborate with Professor Einstein on research in non-linear
refractions in dynamic systems: $350/day for 10 days plus $125.60 for
travel reimbursement
16. SIGNATURES/APPROVALS: By my signature I certify that all information provided on this form is true, that it is correct to the best of my
knowledge, and that I have verified it.
NAME OF PERSON REQUESTING CHECK
SIGNATURE OF PERSON REQUESTING CHECK
Albert Einstein
NAME OF APPROVER
CIMS SPO
TEL. NUMBER
x89999
SIGNATURE OF APPROVER
TEL. NUMBER
x81111
For additional forms and instructions, see Controller’s Division Web site (www.nyu.edu/cdv).
DATE
04/23/02
DATE
04/24/02
TO BE COMPLETED ONLY WHEN PAYMENT (EXCLUSIVE OF REIMBURSEMENT) IS
GREATER THAN $3,000
NEW YORK UNIVERSITY
Form IND4000A
(LAST REVISED APRIL 16, 2002)
INDEPENDENT CONTRACTOR QUESTIONNAIRE
This is an attachment to Form IND4000 (Payment to Individuals Form) and should be completed only when box 2(d)(ii) is marked.
PAYEE’S FULL NAME (FIRST, MIDDLE INITIAL, LAST)
PAYEE’S SOCIAL SECURITY NUMBER OR ITIN
Maria T. Jones
001
─
99
─
5678
SECTION ONE
AVAILABILITY OF SERVICES TO THE PUBLIC
1.1
Does Payee have own business and does this business offer services to the public?
If NO, stop here. Payee falls within employee classification and payment should be processed through the Payroll system.
✘
S
YES
S
NO
S
YES
S
✘
NO
S
YES
✘
S
NO
S
YES
✘
S
NO
S
YES
S
✘
NO
S
YES
S
✘
NO
S
YES
✘
S
NO
S
YES
S
✘
NO
FORMER NYU EMPLOYEE PERFORMING SIMILAR FUNCTIONS
1.2
Is Payee a former employee of NYU performing functions similar to former position?
If NO, please proceed to Section Two.
If YES, please provide some documentation to show that Payee offers services to the general public (e.g., business card, advertisement,
customer list, etc.). NYU needs such documentation on file because the IRS assumes all work done by former employees should be
paid through Payroll. NYU is willing to argue the point as long as documentation is available. If documentation is available, proceed to
Section Two. If no documentation is available, stop here; payment should be processed through the Payroll system.
SECTION TWO
CONTROL OVER FUNCTIONS AND WORK PATTERNS
2.1
Are Payee’s methods or activities controlled or directly supervised by an NYU employee?
(An employee is required to comply with instructions on when, where, and how work is performed. Even when no supervision or
instructions are given, an employee is required to follow the protocol, routines and schedules set by NYU. Independent Contractors
are not subject to the same factors.)
TRAINING
2.2
Does NYU provide or will provide training to Payee on the manner in which work should be performed?
(An employee is trained to conduct work in a particular manner. Independent Contractors ordinarily use their own methods to
accomplish work and are not required to be trained on how they should perform services.)
SET HOURS OF WORK AND PREMISES WHERE WORK IS PERFORMED
2.3
Does or will NYU set Payee’s hours of work or define where work should be performed?
(An employee performs work during hours established by NYU and is required to perform work on premises determined by NYU.)
FUNCTIONS SIMILAR TO EXISTING POSITION
2.4
Is Payee providing services similar to those provided by a current NYU employee?
(The services of an Independent Contractor are usually engaged when the resources, skills, or expertise required for particular tasks
are not available within NYU. If Payee is performing functions similar to those of a current employee, he/she may be subject to NYU
direction or control.)
MEETINGS
2.5
Is Payee required to attend NYU employee meetings other than to get background project information or to give project reports?
(An employee is required to attend employee meetings and events as part of his/her duties. An Independent Contractor is not required
to do the same but may be requested to provide regular updates according to mutually agreed-upon protocol and schedule.)
SUPERVISORY CAPACITY
2.6
Is Payee managing NYU employees in their performance of regular work duties?
(Supervisors and managers are normally NYU employees. An Independent Contractor may direct an employee on a specific project,
but not on all regular work duties.)
CONCLUSION
If Section One did not direct you to Section Two, an employee/employer relationship exists between Payee and NYU. Payment should be processed through the
Payroll system.
If Section One directed you to Section Two, and
1)
2)
If no more than 1 answer is YES, payment can be made through Accounts Payable.
If 2 or more answers are YES, stop here. An employee/employer relationship exists and payment should be processed through the Payroll system.
SIGNATURES/APPROVALS: In signing this form I certify that all information provided here, including SSN or ITIN, is correct to the best of my knowledge.
PAYEE SIGNATURE (MUST BE PAYEE NAMED ABOVE)
TELEPHONE
(347)999-1111
NYU DEPT
CIMS
NYU AUTHORIZED REPRESENTATIVE
TELEPHONE
x81111
DATE
04/23/02
DATE
04/24/02