OPERS Independent Contractor Form_fillable PDF Form (14).pdf
PDF 249 KB Posted
- Attached to
- Lake Milton ADA Fishing Pier
- Solicitation number
- SRC0000033327
- Issued by
- Mahoning County, Ohio
About this file
This document is an Independent Contractor/Worker Acknowledgment form from the Ohio Public Employees Retirement System (OPERS), located in Columbus, Ohio. The form is designed for individuals providing personal services to a public employer on or after January 7, 2013, who are not considered public employees and will not have contributions made to OPERS. It must be completed within 30 days of beginning service, and requires detailed information about the independent contractor and the public employer, including personal details, service dates, and the nature of services provided.
The form outlines specific criteria for independent contractors under Ohio Administrative Code, including being party to a bilateral agreement, being paid a fee or contractual arrangement, not being eligible for workers' compensation, not appearing on a public employer's payroll, and providing their own supplies and equipment. The document emphasizes that independent contractors are not public employees and will not receive retirement system contributions. It warns that disagreement with the classification may trigger a determination process, and highlights potential implications for retirees returning to work, such as suspension of annuity benefits and potential liability for medical reimbursement accounts.
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Other files
| File | Type | Posted |
|---|---|---|
| Affirmation and Disclosure Form_3-4-22 (4).pdf | ||
| Lake Milton ADA Pier - project location.jpg | JPG image | |
| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys (5).docx | DOCX document | |
| Lake Milton ADA pier - map view.png | PNG image | |
| Lake Milton Dock Schematic a.pdf | ||
| Standard Terms and Conditions (14).pdf | ||
| Ohio Buys Quote Template - Milton fishing pier.docx | DOCX document | |
| Lake Milton ADA Pier - existing abutment.jpg | JPG image | |
| Lake Milton ADA pier - aerial view during draw down.png | PNG image |
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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 .