Independent Contractor_Worker Acknowlegment.pdf

This is a Non-Member Acknowledgment form from the Ohio Public Employees Retirement System (OPERS), issued by OPERS with offices located at 277 East Town Street, Columbus, Ohio 43215-4642. The form is completed by individuals who begin providing personal services to a public employer on or after July 7, 2013, and who are not considered public employees eligible for OPERS contributions. The form must be completed and returned to the retirement system no later than 30 days after the individual begins providing personal services to the public employer. The form can be faxed to 614-857-1152 or emailed to employerservices@opers.org. Individuals receiving benefits from OPERS must also submit form SR-6 (Notice of Re-employment or Contract Services of an OPERS Benefit Recipient) in addition to this acknowledgment form.

The form requires completion of three steps: personal information for the service provider, public employer information to be completed by the employer (including employer name, contact information, employer code, service description, and service dates), and acknowledgment that the provider has been classified as an independent contractor or non-employee and that no OPERS contributions will be made on their behalf. The acknowledgment section informs individuals of their right to request a determination of OPERS eligibility within five years of beginning service, subject to medical documentation requirements if the five-year period has elapsed. The form was revised in May 2022 and requires a handwritten signature with today's date.