DEPARTMENT OF LABOR & INDUSTRY
OFFICE OF UNEMPLOYMENT COMPENSATION TAX SERVICES
Date:
Account Number:
Dear Worker:
Enclosed is Form UC-110(W), Employment Status Questionnaire, for your completion.
The purpose of this questionnaire is to obtain information relative to the agreement that now exists or did exist
between you and while performing services for payment. This information will allow the
Office of Unemployment Compensation (UC) Tax Services to determine your status under the reporting provisions of
the Pennsylvania UC Law.
Please answer all questions completely and provide documentation and additional explanations where necessary. It is
only through the submission of complete, clear, and specific evidence that we can make an accurate determination on
your employment status. However, in the absence of information submitted by you, we will make its determination
based on all available information.
Please return this completed form within 10 days to the Office of UC Tax Services via email or by mail to PO Box
60848, Harrisburg, PA 17106-0848.
If you have any questions, please contact at
or .
Thank you for your cooperation.
Please do not copy or duplicate this form for any other use.
Department of Labor & Industry | Office of UC Tax Services
651 Boas Street | Harrisburg, PA 17121-0750 | www.uc.pa.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-110(W) REV 06-22 (Page 1 of 6)
EMPLOYMENT STATUS QUESTIONNAIRE
To be completed by the individual who received compensation for services from
PART I
1. Your Name
Your Social Security Number
Your Home Address
Your Telephone Number(s)
Your E-Mail Address
2. Do you own or operate your own business? Yes No (Skip to Part II)
Business Name
Business Address
Business Telephone Number(s)
Federal Identification Number (FEIN)
Primary Business Activity
Type of Entity (check one) Sole Proprietorship Partnership
Corporation Limited Liability Company
Other (Explain)
Do you employ others? Yes No
Do you have any of the following items? If “yes,” please provide copy.
Business Cards Yes No
Invoices/Sales Receipts Yes No
Advertisements Yes No
Website Address: Yes No
General Liability Insurance Yes No
Workers Compensation Insurance Yes No
Telephone Directory Listing Yes No
1099s issued to your business from another business Yes No
If you are a gig-worker, please continue to Part III of this questionnaire.
PART II
1. Your Occupation or Title for this business
Address, Phone Number & Contact Person for this business
Dates worked for this business
2. Briefly describe the services you perform(ed) for the business
3. Are these services performed in PA? Yes No
4. Do you have a resolved/or pending IRS “Determination of Worker Status” (SS-8) for this work?
Yes (provide copy) No
5. How did the business retain your services? (Check all that apply)
Bid/Estimate Application Answered an Ad
Interview Other (Explain)
Department of Labor & Industry | Office of UC Tax Services
651 Boas Street | Harrisburg, PA 17121-0750 | www.uc.pa.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
UC-110(W) REV 06-22 (Page 3 of 6) Equal Opportunity Employer/Program
EMPLOYMENT STATUS QUESTIONNAIRE
6. Where did you perform these services? (Check all that apply)
Business premises Location Provided or Established by Business
Your Office/Shop Location of Client or Customer of Business
Your Home Other Locations (Explain)
7. How are you paid?
Salary Rate $ per Commission Rate per
Hourly Rate $ per hour Piecework Rate per
Other (Explain)
8. Is there an agreement between you and the Business as to the services that you are to perform?
Yes No
If “Yes”, is this agreement: Written (Provide a copy) Oral (Explain the terms)
9. How is your schedule determined? (Check all that apply)
Needs of the Business Needs of the Business’s client or customer
Worker’s choice Other (Explain)
10. Were you free from control or direction in the performance of your work? Yes No
If “No”, please explain how your work was supervised:
11. Are you reimbursed for any expenses? Yes No
If “Yes”, please explain (i.e. gasoline, mileage, tools, supplies, cell phone, etc.)
12. Do you present an invoice for work completed? Yes No
If “Yes”, please answer the following:
Does this invoice include the cost of material, as well as labor? Yes No
Is this a custom printed invoice? Yes No
13. Furnish any additional information you consider pertinent:
PART III
1. Do you work/provide services for a business in the gig economy? Yes No
2. Business Name
3. Business Address
4. Business Telephone Number
5. FEIN
6. Primary Business Activity
Department of Labor & Industry | Office of UC Tax Services
651 Boas Street | Harrisburg, PA 17121-0750 | www.uc.pa.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-110(W) REV 06-22 (Page 4 of 6)
EMPLOYMENT STATUS QUESTIONNAIRE
7. Type of Entity (Check one)
Sole Proprietorship Partnership
Corporation Limited Liability Company
Other (Explain)
8. Your occupation or title for this business
9. If applicable, Address, Phone Number & Contact Person for this business
10. Dates you worked for this business
11. When did you apply to perform services for this business?
12. How did you apply to perform services for this business? Please state whether you were interviewed and/or had a
background check performed.
13. Briefly describe the services you perform(ed) for the business
14. Are the services performed in PA? Yes No
15. Where did you perform services for the business? (Check all that apply)
Business premises Location provided or established by business
Your office/shop Location of client or customer
Your home Your vehicle
Other
16. Did the business retain your services through the execution of software license agreement/online service agreement? If so,
please attach a copy. Yes No
17. Do you pay a service fee to the business? Yes No
18. Were you provided with software, websites, applications payment services and related support services from the business?
Yes No
19. Do you use your personal vehicle to provide services for the business? Yes No
20. Do you use your personal cell phone to provide services for the business? Yes No
21. Did the business provide criteria for the authorized use of your vehicle/cell phone? Yes No
If so, what criteria?
22. Does the business provide requirements for using the application (i.e., do I need to use it once a month to remain active)?
Yes No
23. Was a placard provided to you by the business? Yes No
24. Can the business deactivate your account? Yes No
25. Are you free from control or direction in the performance of your work? Yes No
a. If no, please explain how your work is supervised.
26. Were you subject to performance evaluations by the business? Yes No
27. How is your schedule determined?
28. Are your reimbursed for any expenses? (i.e., gas, mileage, tools, cell phone etc.) Yes No
29. Do you present an invoice for work completed? Yes No
30. How are you paid?
31. Are you able to perform the same services for other companies at the same time you are logged in for the above company?
Yes No
Department of Labor & Industry | Office of UC Tax Services
651 Boas Street | Harrisburg, PA 17121-0750 | www.uc.pa.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-110(W) REV 06-22 (Page 5 of 6)
EMPLOYMENT STATUS QUESTIONNAIRE
32. Furnish any additional information you consider pertinent.
PART IV
I HEREBY CERTIFY THAT THE FOREGOING INFORMATION IS TRUE AND CORRECT, TO THE BEST OF MY KNOWLEDGE AND BELIEF. I
ACKNOWLEDGE THAT ALL ANSWERS ARE SUBJECT TO VERIFICATION BY THE DEPARTMENT OF LABOR & INDUSTRY.
Signature of Worker Date
Department of Labor & Industry | Office of UC Tax Services
651 Boas Street | Harrisburg, PA 17121-0750 | www.uc.pa.gov
Auxiliary aids and services are available upon request to individuals with disabilities.
Equal Opportunity Employer/Program
UC-110(W) REV 06-22 (Page 6 of 6)
