OPERS Independent Contractor Form_fillable PDF Form (6).pdf

227 KB Posted

Attached to
OWC - YSI EXO2 and Supporting Sensors
Solicitation number
SRC0000023875
Issued by
Erie County, Ohio

About this file

Written by GovTribe AI ·

This document is an OPERS Independent Contractor/Worker Acknowledgment form that is required to be completed by individuals who begin providing personal services to a public employer in Ohio on or after January 7, 2013. The form collects the individual's personal information, including their name, social security number, date of birth, and whether they are a current OPERS or other retirement system benefit recipient. It also requires the individual to provide information about the public employer they are providing services to, including the employer's name, employer contact information, the service being provided, and the start and end dates of the service.

The form is meant to acknowledge that the individual is not considered a public employee and will not have contributions made to OPERS. The form must be completed within 30 days of the individual beginning to provide services to the public employer.

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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 .