OPERS Independent Contractor Form_fillable PDF Form (18).pdf
PDF 249 KB Posted
- Attached to
- St. Marys Fish Hatchery 10 KW generator
- Solicitation number
- SRC0000028640
- Issued by
- Ashland County, Sandusky City, Ohio
About this file
This document is an OPERS (Ohio Public Employees Retirement System) Independent Contractor/Worker Acknowledgment form designed for individuals providing personal services to public employers. The form is specifically for independent contractors who begin work on or after January 7, 2013, and will not have contributions made to the OPERS retirement system. The form must be completed within 30 days of starting service and requires detailed information about the individual contractor and the public employer, including personal details, employer information, service start and end dates, and contact information.
The form is primarily an administrative document for tracking independent contractors providing services to public employers in Ohio. It serves as a formal acknowledgment and documentation mechanism for non-employee service providers, ensuring proper classification and record-keeping for the Ohio Public Employees Retirement System. The form is fillable and includes sections for personal information, employer details, and service parameters, with a requirement for submission within a specific timeframe after service commencement.
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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 .