E_OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- WMD2 Dormant Stem Herbicide Application - FY26
- Solicitation number
- SRC0000032031
- Issued by
- Hancock County, Ohio
About this file
This document is an Independent Contractor/Worker Acknowledgment form issued by the Ohio Public Employees Retirement System (OPERS), located in Columbus, Ohio. The form is designed for individuals who begin providing personal services to a public employer on or after January 7, 2013, but are not considered public employees (such as independent contractors). The form must be completed within 30 days of beginning service and includes sections for personal information, public employer details, and a comprehensive acknowledgment of the contractor's status.
The form clarifies that as an independent contractor, the individual will not have contributions made to OPERS and is subject to specific criteria defined in Ohio Administrative Code. These criteria include being paid by contractual arrangement, not being eligible for employee benefits, not appearing on a public employer's payroll, providing own supplies and equipment, and receiving an Internal Revenue Service Form 1099 for tax reporting. The document also explains potential implications, such as the ability to request a determination of public employee eligibility within five years of service, and warns that the contractor may be liable for certain expenses and reimbursements under the OPERS Health Reimbursement Arrangement (HRA) and OPERS Retiree Medical Account (RMA).
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Text version
OPERS
INDEPENDENT CONTRACTOR/WORKER
ACKNOWLEDGMENT
Ohio Public Employees Retirement System 277 East Town Street, Columbus, Ohio 43215-4642
Employer Services: 1-888-400-0965 www.opers.org
This form is to be completed if you are an individual who begins providing personal services to a public employer on or after
Jan. 7, 2013 but are not considered by the public employer to be a public employee (e.g, you are an independent contractor) and will not have contributions made to OPERS. This form must be completed not later than 30 days after you begin providing personal services to the public employer.
STEP 1: Personal Information
Social Security Number
Date of Birth
Month Day
I First Name
Year
I
Name of Current Employer
Ml Last Name
0 I am an OPERS or other retirement system benefit recipient
STEP 2: Public Employer Information
Name of Public Employer for Which You Are Providing Personal Services
Employer Contact
First Name Ml Last Name
Employer Code Employer Contact Phone Number
Service Provided to Public Employer
Start Date of Service End Date of Service
Month Day Year Month Day Year
I I I j
PEDACKN (Revised 6/2017) Page 1 (continued on back)
File details come from the government source that posted it. Updated .