OPERS Independent Contractor Form_fillable PDF Form (21).pdf
PDF 249 KB Posted
- Attached to
- AHWA Bison Fence & Enclosure
- Solicitation number
- SRC0000028469
- Issued by
- Montgomery County, Ohio
About this file
This is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form that must be completed by individuals providing personal services to public employers in Ohio who are classified as independent contractors rather than public employees. The form must be submitted within 30 days of beginning services and contains sections for personal information, public employer details, and service dates. The form is used to formally acknowledge that the contractor understands they will not have OPERS contributions made on their behalf.
The document outlines eight key criteria defining an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including payment arrangements, ineligibility for benefits, and tax reporting requirements. Contractors have the right to request an OPERS determination of their employment classification within five years of beginning services. The form explicitly states that independent contractors are not eligible for OPERS contributions or certain medical expense reimbursements under the OPERS Health Reimbursement Arrangement (HRA) and OPERS Retiree Medical Account (RMA) programs. Both the public employer and OPERS must retain copies of this acknowledgment form.
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| Affirmation and Disclosure Form_3-4-22 (9).pdf | ||
| AHVC Bison Enclosure Scope Map.docx | DOCX document | |
| 20240708_ODNR AHVC_Conformed Drawings 138.pdf | ||
| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys (10).docx | DOCX document | |
| Standard Terms and Conditions (19).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 .