OPERS Independent Contractor Form_fillable PDF Form (18).pdf
PDF 249 KB Posted
- Attached to
- St. Marys Fish Hatchery well repair. State and local contract opportunity
- Solicitation number
- SRC0000032298
- Issued by
- Ashland County, Ohio
About this file
This document is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form designed for individuals providing personal services to a public employer on or after January 7, 2013, who are not considered public employees. The form requires independent contractors to acknowledge their classification and understand that no retirement system contributions will be made on their behalf. Contractors must complete this form within 30 days of beginning service, and it outlines specific criteria defining an independent contractor under Ohio Administrative Code.
The form details important legal and financial implications for independent contractors, including ineligibility for workers' compensation, employee fringe benefits, and public employer payroll. It also explains that contractors may be subject to a five-year review period where OPERS can request a determination of the contractor's employment status. Additionally, the document clarifies that independent contractors who are retired and return to work have specific restrictions, such as potential suspension of annuity benefits and limitations on reemployment allowances or reimbursements.
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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 .