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Free Michigan Uia 1015 C Template in PDF

The Michigan UIA 1015 C form is a Worker’s Questionnaire designed to help determine an individual's employment status for unemployment benefits. This form collects essential information about your relationship with your employer, including your job duties and payment structure. Completing this form accurately is crucial, as failure to provide the necessary details may lead to decisions made without your input.

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Structure

The Michigan UIA 1015 C form serves as a crucial tool for determining an individual's employment status when filing for unemployment benefits. This form, officially known as the Worker’s Questionnaire to Determine Employment Status, is designed to collect detailed information about the worker's relationship with their employer. It includes sections that ask for basic identifying information, such as the worker's name, address, and Social Security number, as well as the employer's name and federal identification number. The completion of this form is voluntary but highly recommended; failure to provide the necessary information could lead to a determination being made without the worker's input. Key questions on the form address whether the individual considers themselves an employee or self-employed, the nature of their work, and the terms of their employment. Additional inquiries delve into the specifics of the worker's duties, the presence of written agreements, and whether they performed similar services for other employers. The form also seeks to clarify the extent of control the employer had over the worker’s activities, the payment structure, and any benefits received. By thoroughly answering these questions, workers can aid the Unemployment Insurance Agency in accurately assessing their eligibility for benefits.

Form Example

UIA 1015-C	STATE OF MICHIGAN	Authorized by
(Rev. 5-11)	STATE OF MICHIGAN	MCL 421.1, et seq.
(Rev. 5-11)		MCL 421.1, et seq.
	LICENSING AND REGULATORY AFFAIRS	Completion of this
	UNEMPLOYMENT INSURANCE AGENCY	form is voluntary.
	UNEMPLOYMENT INSURANCE AGENCY

www.michigan.gov/uia

WORKER’S QUESTIONNAIRE TO DETERMINE EMPLOYMENT STATUS

For Calendar Year(s)

________________________Case Number

Date __________________________

Worker’s Name, Address, and Social Security Number

Company’s Name and Address

Employer Federal ID Number (if known):

Completing this form will help us determine your employment status with the above employer and assist us in processing your claim for unemployment beneits. FAILURE TO PROVIDE THIS INFORMATION MAY RESULT IN A DETERMINATION BEING MADE WITHOUT YOUR PARTICIPATION. Type or print your answers clearly and return this form within 10 days from the above date to:

(Indicate address where form should be returned)

If you have questions contact _____________________________________________	___________________________________
(Please print name)	(Telephone Number)

1.Did you consider yourself: (Indicate A or B and give reason for your answer)

A.An employee of the above-named company?_______________________________________________________

_____________________________________________________________________________________________

B.Self-Employed?______________________________________________________________________________

_____________________________________________________________________________________________

2.	Are you still performing services for this employer	YES	NO

	If NO, do you expect to return to work with this employer?	YES	NO
	If YES, give dates of employment __________________________________________________________________

3.	..............Has a previous ruling regarding your employment status with this employer been issued?	YES	NO
	If YES, who issued the ruling and when was ruling issued? ______________________________________________
	(Attach copy of ruling)

4.What is the employer’s business? __________________________________________________________________

_____________________________________________________________________________________________

5.How did you obtain work with this employer?__________________________________________________________

_____________________________________________________________________________________________

6.What service(s) did you perform?___________________________________________________________________

_____________________________________________________________________________________________

7.Where were the service(s) performed? (Give address) __________________________________________________

_____________________________________________________________________________________________

8. Was the work performed under a written agreement?	YES	NO
If YES, attach a copy of agreement.
9. Did you perform similar services for others while performing services for this employer	YES	NO

If YES, please provide the name(s) of other individuals for whom you have provided similar services in the last twelve months __________.

Page 1 of 3

10.	Did others perform similar services for this employer?	YES	NO
	If YES, how many? __________
........................................................................11. Did you submit invoices for the work you performed?		YES	NO
	If YES, please provide copies of invoices/bills that you submitted.
12.	Could either you or the employer terminate the services you performed at any time?	YES	NO
12.		YES	NO

Explain _______________________________________________________________________________________

_____________________________________________________________________________________________

13.What equipment, tools, expenses, materials, and/or supplies were provided to you by the employer to perform these services?

_____________________________________________________________________________________________

14.What equipment, tools, materials and/or supplies did you provide to perform these services? ____________________

_____________________________________________________________________________________________

15.

Did the employer reimburse you for any expenses you incurred?

YES

Please explain your answer _______________________________________________________________________

_____________________________________________________________________________________________

16. Were you required to report to work at a speciied time: e.g., 8:00 a.m. - 5:00 p.m.?

YES

If YES, who determined the hours? _________________________________________________________________

Who kept records of hours worked?_________________________________________________________________

17.

Were you required to call someone if you were unable to report to work?

YES

If YES, who?___________________________________________________________________________________

18.

How did you report your time to the company? Time clock

Sign-in sheet

Other

If other, indicate reporting method and who provided it? ________________________________________________

19.

Did the employer direct and control your day-to-day activities?

YES

(Did the employer tell you what to do, when and how to do it?)

If YES, how?___________________________________________________________________________________

_____________________________________________________________________________________________

20.

Was there a supervisor on the job that you reported to?

YES

If YES, who? _________________________________

21.

Did you employ assistants?

YES

(If YES, answer A through C. If NO, go to #22.)

A. Were the assistant’s subject to employer’s approval?

YES

B. Do you determine the hours that assistants work?

YES

C. How was the assistants’ pay determined? _________________________________________________________

22.

Was your job reviewed for satisfactory performance?

YES

If YES, who performed review? ____________________________________________________________________

Who paid for the expenses of correcting unsatisfactory work? ____________________________________________

23.How much were you paid for the services you performed? (Be speciic; e.g., $8.50 per hour [salary, commission, piece, square foot, etc.].) _________________________________________________________________________

_____________________________________________________________________________________________

24.How was the pay rate determined? _________________________________________________________________

_____________________________________________________________________________________________

Page 2 of 3

25.

Were deductions taken out of your paycheck:

e.g., income tax, social security withholding, etc.?

YES

If YES, identify deduction(s) _______________________________________________________________________

26.

Did you receive a W-2?

YES

Indicate year(s) ________________

27.

Did you receive a 1099?

YES

Indicate year(s) ________________

28.

................................................Were you covered by Workers’ Disability Compensation Insurance?

YES

If YES, who paid for coverage? ____________________________________________________________________

29. Did you receive any beneits: e.g., health insurance, life insurance, sick pay, vacation pay, etc?

YES

If YES, list beneits ______________________________________________________________________________

30. Did you have a Federal Employer Identiication Number (FEIN)?

YES

If YES, give number _____________________________________________________________________________

31. Did you ile an “assumed” name?

YES

If YES, what county ______________________________________________________________________________

32.

Did you pay state, federal, social security and Medicare taxes as

a self-employed individual?

YES

33. Did you ile a business income tax return?

YES

If YES, what is the title of the form? (For example, Schedule C, Form 1120) _________________________________

34.

Were you licensed?

YES

If YES, by which organization(s) are you licensed? _____________________________________________________

If not licensed in your name provide name, type of license, organization, etc. _________________________________

35. Did you maintain an ofice or other place of business?

YES

If YES, what is the address? ______________________________________________________________________

If YES to #35, did the employer pay any part of the rent? ________________________________________________

36.

Did you advertise as being available to the general public by listing your services

in the telephone directory or and other publications?

YES

If YES, identify _________________________________________________________________________________

38.ADDITIONAL COMMENTS: (In the space below, you may provide any additional information you feel would be beneicial in determining your employment status. Use reverse if necessary.)

______________________________________________________________________________________________

CERTIFICATION

I hereby certify that the answers given on this form are true and complete to the best of my knowledge and belief.

_______________________________________________	_______________________	______________________________
Signature	Date	Telephone Number

(Include Area Code)

LARA is an equal opportunity employer/program.

Page 3 of 3

▼ Michigan Uia 1015 C PDF Form

Document Specs

Fact Name	Details
Form Purpose	The UIA 1015-C form is designed to help determine a worker's employment status for unemployment benefits in Michigan.
Governing Law	This form is authorized by the Michigan Compiled Laws (MCL) 421.1, et seq., which governs unemployment insurance in the state.
Voluntary Completion	Completing the form is voluntary; however, failure to provide the necessary information may lead to a determination made without the worker's input.
Submission Deadline	Workers must return the completed form within 10 days from the date indicated on the form to ensure timely processing of their claim.
Information Required	The form requires various details, including the worker's name, address, Social Security number, and the employer's information.
Employment Status Inquiry	Workers must indicate whether they consider themselves employees or self-employed and provide reasons for their choice.
Service Performance	The form asks about the nature of services performed, including whether they were done under a written agreement and where the services took place.
Payment Details	Workers must specify how much they were paid and how the pay rate was determined, ensuring clarity on compensation.
Tax Documentation	The form inquires whether workers received tax documents such as W-2s or 1099s, which can affect their unemployment claims.
Certification Requirement	At the end of the form, workers must certify that their answers are true and complete, adding a layer of accountability to the information provided.

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