OPERS_Independent_Contractor_Form_fillable_PDF_Form__6_ (1).pdf

227 KB Posted

Attached to
2025 Old Woman Creek Window Replacement
Solicitation number
SRC0000028633
Issued by
Erie County, Ohio

About this file

Written by GovTribe AI ·

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 without being considered a public employee. The form must be completed within 30 days of beginning service and is specifically applicable to independent contractors who start work on or after January 7, 2013 and will not have contributions made to OPERS.

The form captures detailed personal and employer information, including Social Security Number, date of birth, name, current employer, public employer details, service start and end dates, and contact information. It serves as an official documentation mechanism for independent contractors to formally acknowledge their non-employee status when providing services to public employers in Ohio, with the primary purpose of clarifying retirement system participation and service classification.

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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)

10121369 Highlight

SSN1:
SSN2:
SSN3:
DOB1:
DOB2:
DOB3:
First Name:
MI:
Last Name:
Name of Current Employer:
OPERS recipient check box: Off
Name of Public Employer:
Employer Contact First Name:
Employer Contact MI:
Employer Contact Last Name:
Employer Code:
Employer Contact Phone1:
Employer Contact Phone2:
Employer Contact Phone3:
Service Provided to Employer:
Service Start Date1:
Service Start Date2:
Service Start Date3:
Service End Date1:
Service End Date2:
Service End Date3:

File details come from the government source that posted it. Updated .