<html> <head> <meta name=Generator content="Microsoft Office HTML Filter 2.0"> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <style> <!-- --> </style> </head> <body lang=EN-US> <div> <p align=center><a name="_GoBack"></a><b>CHAPTER 47:03:10</b></p> <p align=center><b>&nbsp;</b></p> <p align=center><b>INDEPENDENT CONTRACTOR AFFIDAVIT OF EXEMPT STATUS</b></p> <p>Section</p> <p><a href="DisplayRule.aspx?Rule=47:03:10:01">47:03:10:01</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Method for completing affidavit of exempt status.</p> <p><a href="DisplayRule.aspx?Rule=47:03:10:02">47:03:10:02</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Filing of affidavit of exempt status.</p> <p><a href="DisplayRule.aspx?Rule=47:03:10:03">47:03:10:03</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Applicability of affidavit of exempt status.</p> <p><a href="DisplayRule.aspx?Rule=47:03:10:0A">Appendix A</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Affidavit of Exempt Status.</p> <p><a href="DisplayRule.aspx?Rule=47:03:10:0B">Appendix B</a>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Exempt Status Fact Sheet.</p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 47:03:10:0A Affidavit of Exempt Status.</title> <META NAME="Keywords" Content="Administrative Rules 47:03:10:0A"> <META NAME="Description" Content="Administrative Rules 47:03:10:0A Affidavit of Exempt Status."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:49.7pt 1.0in 49.7pt 63.35pt;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><a name="_GoBack"></a><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>DIVISION OF INSURANCE</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>AFFIDAVIT OF EXEMPT STATUS</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>Chapter 47:03:10</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>APPENDIX A</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>SEE: &#167;&nbsp;47:03:10:01</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><b><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source:</span></b><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'> 41 SDR 219, effective July 1, 2015.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-bottom:0in;margin-bottom:.0001pt; text-align:center;line-height:normal'><b><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>APPENDIX A</span></b></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>STATE OF SOUTH DAKOTA )</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; ) SS&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; AFFIDAVIT OF EXEMPT STATUS</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>COUNTY OF ______________ </span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>I state under oath as follows:</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:45.0pt;margin-bottom:.0001pt;text-align:justify;text-indent:-45.0pt; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 1.&nbsp;&nbsp;I, ______________________, operating as_____________________________________,&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Independent Contractor)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Independent Contractor's Business Name)</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; have agreed to provide services for ____________________ during calendar year _____.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (General Contractor)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp; (Year)</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 2.&nbsp;&nbsp;I have read, signed, and attached the Exempt Status Fact Sheet and understand that an Independent Contractor is one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 3.&nbsp;&nbsp;I understand that based upon the representations in this Affidavit of Exempt Status that I have signed, I am requesting that the Contractor identified above consider my business to be that of an independent contractor; that I am not an employee under the Workers' Compensation Act and the policy issued by ___________________________________.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp;&nbsp; General Contractor's Insurance Carrier</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 4.&nbsp;&nbsp;I am an independent contractor, not an employee of the contractor, and I do not want workers' compensation insurance.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 5.&nbsp;&nbsp;I am not an employer for the purposes of the Workers' Compensation Act.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 6.&nbsp;&nbsp;I have read, signed, and attached the Exempt Status Fact Sheet describing what an Independent Contractor is and the information provided is not the result of force, threats, coercion, compulsion, or duress.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 7.&nbsp;&nbsp;I understand that the execution of this affidavit shall establish a rebuttable presumption that I am not an employee for purposes of the Workers' Compensation Act.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 8.&nbsp;&nbsp;I understand that by signing this affidavit I will not be eligible for compensation under the South Dakota Workers' Compensation Law.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 9.&nbsp;&nbsp;I understand the execution of this affidavit does not affect the rights or coverage of any employee of the individual executing the affidavit.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; 10.&nbsp;I understand that soliciting or providing false information on this affidavit with actual knowledge is a Class 2 misdemeanor.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Independent Contractor Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _______________________________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Independent Contractor Name&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Title</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Subscribed and sworn to before me this ________ day of _____________, 20 _____.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________________ </span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Notary Public- South Dakota</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Seal)</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>My commission expires:_____________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; ___________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>General Contractor Signature&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Date</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>________________________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; _______________________________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>General Contractor Name&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Title</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Subscribed and sworn to before me this _________ day of _____________, 20 _____.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_________________________________</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Notary Public-South Dakota</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (Seal)</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>My commission expires:_____________.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;line-height: normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 47:03:10:0B Exempt Status Fact Sheet.</title> <META NAME="Keywords" Content="Administrative Rules 47:03:10:0B"> <META NAME="Description" Content="Administrative Rules 47:03:10:0B Exempt Status Fact Sheet."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; 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margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>DEPARTMENT OF LABOR AND REGULATION</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>DIVISION OF INSURANCE</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>FORM OF EXEMPT STATUS FACT SHEET ATTACHMENT TO</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>AFFIDAVIT OF EXEMPT STATUS</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>Chapter 47:03:10</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>APPENDIX B</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>SEE: &#167;&nbsp;47:03:10:01</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><span style='font-size:12.0pt;font-family: "Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Source:&nbsp;&nbsp;41 SDR 219, effective July 1, 2015.</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><b><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>APPENDIX B</span></b></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><b><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>&nbsp;</span></b></p> <p class=MsoNormal align=center style='margin-top:0in;margin-right:0in; margin-bottom:0in;margin-left:.6in;margin-bottom:.0001pt;text-align:center; text-indent:-.6in;line-height:normal'><b><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>EXEMPT STATUS FACT SHEET</span></b></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-top:0in;margin-right:0in;margin-bottom:0in; margin-left:.6in;margin-bottom:.0001pt;text-align:justify;text-indent:-.6in; line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>An independent contractor is defined by law as one who engages to perform certain services for another, according to his own manner and method, free from control and direction of the contractor in all matters connected with the performance of the service, except as to the result or product of the work. Below are statements to help you decide if you are an independent contractor. No one statement is controlling, and your status is based on all the facts in your situation.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>1.&nbsp;&nbsp;The nature of the contract between you and the contractor shows you are independent from the contractor. For example: Is there a written contract where you agree that you are an independent contractor? Do you maintain commercial general liability insurance or other business insurance?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>2.&nbsp;&nbsp;The contractor exercises no control over the details of your work or independence. Do you exercise control over the details of the work? Do you create plans or specifications for the job? Do you set your own work hours?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>3.&nbsp;&nbsp;You are engaged in a distinct occupation or business for others. Do you work for a company or individual other than the Contractor? Do you work for a competitor of the Contractor? Does your business have a logo or uniform?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>4.&nbsp;&nbsp;Do you have a sales tax license? Do you have a contractor's excise tax license?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>5.&nbsp;&nbsp;You cannot complete the affidavit if you are a subcontractor who is also an employer. Do you have employees?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>6.&nbsp;&nbsp;Is your business incorporated? If you do business as a corporate entity you are typically considered an employee of the corporation and cannot complete the affidavit.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>7.&nbsp;&nbsp;Your job is the kind of occupation where the work is usually performed by a specialist without supervision, and not under the direction of the contractor.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>8. Your occupation requires special skills, license, education, or training.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>9.&nbsp;&nbsp;The contractor does not supply the things needed to perform your job such as the tools and the place of work. Do you operate a vehicle owned by the contractor? Was the work performed at your business or the contractor's business location or jobsite?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>10.&nbsp;&nbsp;The length of the job and how long you have worked for the Contractor does not show that you are really an employee. For example: Is this a one-time job, or will you be doing this for the contractor regularly?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>11.&nbsp;&nbsp;You are paid as a separate contractor, not as an employee. Do you invoice the Contractor for your services? Do you file a federal income tax return for your business? Do you expect to receive an IRS Form 1099 from the Contractor?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>12.&nbsp;&nbsp;Your work is not the regular business of the Contractor.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>13.&nbsp;&nbsp;You do not have the right to terminate the relationship without liability. For example: If you quit before the job is finished, is there a penalty?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Based upon these factors, do you believe that you are an independent contractor with exempt status?</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>_______________________&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; Signature ________________________________________</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp; (WRITE YES OR NO)&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; &nbsp;&nbsp; (INDEPENDENT CONTRACTOR/EXECUTOR)</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>Note: An employer who knowingly solicits or requires an employee or subcontractor to execute an affidavit when the employer knows that the employee or subcontractor is required to be covered under a workers' compensation insurance policy is guilty of a Class 2 misdemeanor.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;line-height: normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 47:03:10:01 Method for completing affidavit of exempt status.</title> <META NAME="Keywords" Content="Administrative Rules 47:03:10:01"> <META NAME="Description" Content="Administrative Rules 47:03:10:01 Method for completing affidavit of exempt status."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><a name="_GoBack"></a><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>47:03:10:01.&nbsp;&nbsp;Method for completing affidavit of exempt status.</b> If an independent contractor elects to complete the affidavit of exempt status as provided in Appendix A, the following are applicable:</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (1)&nbsp;&nbsp;The affidavit of exempt status and the exempt status fact sheet attachment, as provided in Appendix B, must be completed before beginning work on the project specified in the affidavit for the general contractor;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (2)&nbsp;&nbsp;Both the independent contractor and the general contractor shall sign the affidavit of exempt status; and</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; (3)&nbsp;&nbsp;A copy of the completed affidavit of exempt status must be provided to the independent contractor and the general contractor.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 41 SDR 219, effective July 1, 2015.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=62-1-20">62-1-20.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=62-1-20">62-1-20.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 47:03:10:02 Filing of affidavit of exempt status.</title> <META NAME="Keywords" Content="Administrative Rules 47:03:10:02"> <META NAME="Description" Content="Administrative Rules 47:03:10:02 Filing of affidavit of exempt status."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><a name="_GoBack"></a><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>47:03:10:02.&nbsp;&nbsp;Filing of affidavit of exempt status.</b> If the affidavit of exempt status and the exempt status fact sheet is completed, the general contractor shall provide copies to the general contractor's workers' compensation insurance carrier.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 41 SDR 219, effective July 1, 2015.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=62-1-20">62-1-20.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=62-1-20">62-1-20.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html> <br /><hr><br /><html> <head> <title>Rule 47:03:10:03 Applicability of affidavit of exempt status.</title> <META NAME="Keywords" Content="Administrative Rules 47:03:10:03"> <META NAME="Description" Content="Administrative Rules 47:03:10:03 Applicability of affidavit of exempt status."> <meta http-equiv=Content-Type content="text/html; charset=windows-1252"> <meta name=Generator content="Microsoft Word 14 (filtered)"> <style> <!-- /* Font Definitions */ @font-face {font-family:Calibri; panose-1:2 15 5 2 2 2 4 3 2 4;} /* Style Definitions */ p.MsoNormal, li.MsoNormal, div.MsoNormal {margin-top:0in; margin-right:0in; margin-bottom:10.0pt; margin-left:0in; line-height:115%; font-size:11.0pt; font-family:"Calibri","sans-serif";} @page WordSection1 {size:8.5in 11.0in; margin:1.0in 1.0in 1.0in 1.0in;} div.WordSection1 {page:WordSection1;} --> </style> </head> <body lang=EN-US> <div class=WordSection1> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><a name="_GoBack"></a><span style='font-size:12.0pt; font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>47:03:10:03.&nbsp;&nbsp;Applicability of affidavit of exempt status.</b> The affidavit of exempt status may not be executed by an owner-operator, a person deemed an employee, or a person deemed an employer by Title 62.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Source:</b> 41 SDR 219, effective July 1, 2015.</span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>General Authority:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=62-1-20">62-1-20.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; <b>Law Implemented:</b> SDCL <A HREF="/statutes/DisplayStatute.aspx?Type=Statute&Statute=62-1-20">62-1-20.</A></span></p> <p class=MsoNormal style='margin-bottom:0in;margin-bottom:.0001pt;text-align: justify;line-height:normal'><span style='font-size:12.0pt;font-family:"Times New Roman","serif"'>&nbsp;</span></p> </div> </body> </html>