Virgin Islands Department of Labor Division of Unimployment Compensation P.O. Box 3159, Charlotte Amalie, St. Thomas, V.I. 00803 2353 Kronprindsens Gade, St. Thomas, V.I. 00803 INDEPENDENT CONTRACTOR ANALYSIS NOTE: A separate form should be completed for each job class to be ruled upon. This Form is Being Completed By: 441 Firm Worker Naza_tkddyu ‘: _n 1: --„v.,t., N Na.-k-r-c.4—, cm ,. \ c, c..----..5,,,N s -s•,- - Describe the Nature of the Firm's Business: Name of ClatmantANorker (if applicable). — Worker's Federal Employer Identification Number (if applicable): SSN: Job Title (only one per form): LA M b c rAP raf e Dates of Work of ClaimantANorker From 9 2-4/ 2.0 11 To 2.12_q19 ITEMS A - F BELOW ARE TO BE COMPLETED BY THE FIRM ONLY A) UC Account Number of Firm (if applicable): B) Form of Organization: I= Sole Proprietorship O Partnership In) Corporation a Others (specify) LLC C) Total numti:t workers in this class considered Independent Contractors 0) Total rIUMNAr of workers in this class considered employees: 2. E) If you have both, please explain why: ft4flirrt - e-S — kt&I grAi tit LONA T5f/M OFWATIoiss of 1Ht tsLa.3bS/caireAC-R;q2s- azi pt, FRS /2-4o s P7iZa-r N2 atip te ftr-MCGTs Cit3 krbiA3 14.ntsccatib gY 'tee og IS F) What was the first date the workers in this job class perforrned services of any kind for the firm: COMPL2..) .5.e/cicr 2OL9- INSTRUCTIONS FOR BOTH THE FIRM AND THE WORKER Attach copies of any written agreements, billing statements, applications, or contracts between the firm and the worker. If the agreement was oral, please reduce It to wilting and attach. If any State or Federal Agency has ruled on the same Job class as this worker or another of the same job class, attach a copy of the ruling. (These documents will not be returned.) Attached: EFTA00798211