OPERS Independent Contractor Form_fillable PDF Form (23).pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000028596
- Issued by
- Montgomery County, Ohio
About this file
The document is an OPERS (Ohio Public Employees Retirement System) 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. This form must be completed within 30 days of beginning service and requires detailed personal and employer information, including service dates, contact details, and a comprehensive acknowledgment of the independent contractor classification.
The form explicitly defines an independent contractor under Ohio Administrative Code, outlining specific characteristics such as being party to a bilateral agreement, being paid by contractual arrangement, not being eligible for employee benefits, not appearing on a public employer's payroll, providing own supplies and equipment, and receiving an Internal Revenue Service Form 1099 for tax reporting. The document emphasizes that as an independent contractor, no retirement system contributions will be made, and the individual may be subject to certain restrictions regarding medical reimbursement and retirement benefits, with potential implications for requesting eligibility determination within five years of 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 .