OPERS Independent Contractor Form_fillable PDF Form (11).pdf
PDF 249 KB Posted
- Attached to
- Jackson Fish Unit Building Renovation
- Solicitation number
- SRC0000019687
- Issued by
- Knox County, Ohio
About this file
This document is an Independent Contractor/Worker Acknowledgment form from the Ohio Public Employees Retirement System (OPERS). It is to be completed by individuals who begin providing personal services to a public employer in Ohio 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 starting the service. It requires the individual to provide their personal information, including their social security number and birth date, as well as details about the public employer they are providing services to, such as the employer name, contact information, service start and end dates, and the type of service being provided.
The related state and local contract opportunity is for the Jackson Fish Unit Building Renovation project in Ohio. This project involves replacing the entire roof, gutters, an interior man door, removing and installing a new interior wall, and replacing an awning over the main entrance. It also includes replacing the main entrance door with a steel security door and framing in the window spaces with plywood, insulation, and vinyl siding. The building is approximately 75' x 25' in size.
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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 .