Finance and Administration
 
Professional Personal Services Contract with Independent Contractor
(This contract must be attached to a completed Contract
Approval/Routing Form prior to work commencing.)
Date 2/4/2012
   
CONTRACTOR CONTACT INFORMATION
Contractor
   
Phone Number
   
Email Address
   
Address
   
City
   
State
   
Zip Code
   
 
Are you currently receiving a benefit from the Public Employees' Retirement System of Mississippi?
Yes
No
If the answer is yes, individual must contact the Office of Human Resources (601.432.6134) to discuss eligibility of retirees to earn compensation from the IHL Executive Office prior to completing this form.
   
U.S. Citizen  
Yes
No
Country of Citizenship
Country of Residence
   
Non-resident Alien  
Yes
No
Visa Type
Resident Alien  
Yes
No
   
Incorporated  
Yes
No
Check all Applicable
Small Business
Minority
Woman-Owned
   
U.S. Social Security Number or U.S. Federal Tax ID Number
 
   
STATEMENT OF WORK
IHL has determined that these services are essential and could not satisfactorily be performed by IHL Executive Office employees. Therefore, the Contractor noted above will perform the services and/or tasks as follows.
   
Contractor shall provide the following.
   
Contract Begin Date
Contract Completion Date
   
CONSIDERATION AND COMPENSATION
Account to be Charged
Rate of Pay $
 
(If charged to a Corporation for National and Community Service Grant, consultant daily rate cannot exceed $540.)
   
Payment Terms
   
Services Shall Not Exceed $
Expenses Shall Not Exceed $
   
Nature of Expenses
   
Signed original invoices referencing the IHL contract number should be submitted to the following address:

Mississippi Board of Trustees State Institutions of Higher Learning
Attention: IHL contact will be designated upon execution of contract
3825 Ridgewood Road
Jackson, MS 39211-6453
   
IHL EXECUTIVE OFFICE CONTACT
Name
Phone Number
   
CONTRACTOR CERTIFICATION
I understand I must submit a signed W-9 Form. Also, I have read and agree to the terms noted above and to the general terms and conditions referenced in Appendix A. Please note payments will not be released until a certificate of insurance coverage is provided to IHL as per number two of the general terms and conditions. Please contact the Office of Risk Management at 601.432.6688 before signing the agreement should you have concerns related to compliance with the insurance coverage requirements.

I am an independent Contractor for the IHL; therefore, the IHL is not liable for Social Security Contributions pursuant to Section 418, 42 U.S. Code. Furthermore, IRS Form 1099 will be forwarded at the end of the calendar year if total payments exceed $600.
 
Click on the icon below to download and complete the interactive W-9 Request for Taxpayer Identification Number and Certification.
 
Enter the code below to cofirm your electronic form.
   
Please review the form carefully before submitting.
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Mississippi Institutions of Higher Learning | 3825 Ridgewood Road | Jackson, MS 39211