OPERS Independent Contractor Form_fillable PDF Form (18).pdf
PDF 249 KB Posted
- Attached to
- Herbicide application multiple wildlife areas State and local contract opportunity
- Solicitation number
- SRC0000028901
- Issued by
- Greene County, Ohio
About this file
The document is an Independent Contractor/Worker Acknowledgment form issued by 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 classified as independent contractors and will not have contributions made to OPERS. The form must be completed within 30 days of beginning service and requires detailed information about the individual's personal details, the public employer, and the services being provided.
The form serves as a legal acknowledgment that clarifies the independent contractor's status, outlining specific criteria such as being paid by contractual arrangement, not being eligible for employee benefits, not appearing on the public employer's payroll, and providing their own supplies and equipment. The document explains that as an independent contractor, the individual will not be a contributor to the retirement system and may face limitations on future retirement-related requests. The form requires the contractor's signature and understanding of their classification, potential financial implications, and rights regarding future service determinations.
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Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Herbicide Ohio Buys Request for Quote.docx | DOCX document | |
| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys (9).docx | DOCX document | |
| Maps.pdf | ||
| Standard Terms and Conditions (18).pdf | ||
| Affirmation and Disclosure Form_3-4-22 (8).pdf |
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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 .