Form Center

Out & About Confirmed Acts - Payment Form

2. 1. Your name:*
4. 2. Name of act (i.e. band or group name):*
6. 3. Email address:*
8. 4. Contact Phone Number:*
10. 5. Download a blank IRS W-9 Form. If you have a completed W-9, you can skip to uploading the form below.
    Download blank IRS W-9 Form

    You must complete an updated IRS W-9 form before payment can be processed. Complete the IRS W-9 form, save as a separate file, and upload below in question 6.

12. 6. Upload your completed IRS W-9 Form. *
14. 7. Upload your invoice. *

    An invoice can be a simple document typed up with the following items:

    -Date of service
    -Services performed
    -Amount due
    -Check payable to (must match your W-9)

16. 8. Non-Employee Work Agreement
    
    Under 21 VSA § 601 (14) (F), sole proprietors and partner owners of an unincorporated business whose work: is distinct and separate from the municipality’s work; who control the means and manner of the work performed; hold themselves out as in business for themselves; hold themselves out for work for the general public and do not perform work exclusively for or with another person; and are not treated by the municipality as an employee for purposes of income or employment taxation with regard to the work performed; are not considered workers or employees of the municipality. Work to be performed: Act/performance during Out & About in Essex event. There is no written contract. Work dates begin on October 2, 2021 and end on October 3, 2021 and is not considered to be a normal municipal function that is performed by a Town or Village employee. It is understood that the contractor/performer has the necessary equipment (owned, leased, rented, borrowed or shared) to perform the work.*

    1. YES, I agree to the Non-employee Work Agreement.
    2. NO, I do not agree to the Non-employee Work Agreement. (Feel free to select this option, but note that we will not be able to compensate you.)
20. 9. I hereby certify that I am aware of my right to purchase Workers' Compensation insurance and have elected to purchase Workers' Compensation coverage as described below, or not to purchase Workers' Compensation insurance coverage (please select one):*

    1. I have procured Workers' Compensation Insurance Coverage and will provide details below in question 10.
    2. I am a sole proprietor, or partner owner of an unincorporated business, and as such am not considered to be a worker or employee under the provisions of 21 VSA § 601(14) and will complete Question 11.
24. 10. Complete only if you carry Workers' Compensation coverage. If you do not carry Workers' Compensation coverage, you may skip this question.
26. Carrier:
27. Effective Dates:
29. Limits of Liability:
30. Upload valid Certificate of Insurance
34. 11. Complete only if you DO NOT carry Workers' Compensation Coverage.
    
    I affirm that:
    a. I am not a worker or employee of Town of Essex/Village of Essex Junction;
    b. I am working independently;
    c. I have no employees;
    d. I have not contracted with other independent contractors; and
    e. I understand that I have the right to purchase Workers' Compensation insurance, and I have elected not to purchase Workers' Compensation insurance coverage.

    1. I affirm.
    2. I DO NOT affirm. (Feel free to select this option, but note that we will not be able to compensate you.)
36. 12. Liability Hold-Harmless Agreement
    For use with Sole Proprietors and owner Partners of Unincorporated Businesses
    
    In consideration of the agreement of Town of Essex / Village of Essex Jct. to engage my company and me to perform certain services for the Municipality, my company and I agree, and for myself/ourselves and my/our heirs, executors and administrators agree to indemnify, defend and hold forever harmless Town of Essex / Village of Essex Jct. its officers, agents and employees from and against any and all claims, demands, liabilities, actions, judgments, settlements, damages, costs and expenses (including attorney's fees and disbursements) for injury to or death of any person, including myself, or damage to property arising out of or resulting from any material, product, equipment, vehicle or service supplied by the company or by me, or the agents, servants or employees of either, or from any action or failure to act on the part of myself or the company, or the agents, servants or employees of either, while performing services for, at the behest of, under contract with or on the premises of Town of Essex / Village of Essex Jct.*

    1. I agree.
    2. I DO NOT agree. (Feel free to select this option, but note that we will not be able to compensate you.)
38. Upload valid, current, certificate of insurance, if applicable.
42. 13. By typing my name below, I certify that the above statements and the information provided in this form are true and current to the best of my knowledge.*

    Type your full name if you AGREE.

44. Groups: If you performed with a group and would like to receive separate payments, please submit a separate payment form for each person receiving payment. Ensure that your invoice states only your portion of the confirmed amount the band/act is receiving.
46. Deadline: To receive your payment in person during the weekend of the event, you must submit your invoice and W-9 no later than September 24th. Otherwise, your check will be mailed to you after the event.

    For questions, contact Caitlin Fay at 878-1376 or email cfay@ejrp.org.
Leave This Blank:


47. Submit

* indicates a required field