OPERS Independent Contractor Form_fillable PDF Form (6).pdf
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- Attached to
- 2025 Woody Invasive Treatment - Old Woman Creek
- Solicitation number
- SRC0000027105
- Issued by
- Erie County, Ohio
About this file
This document is the Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form, used for individuals providing personal services to Ohio public employers who are classified as independent contractors rather than public employees. The form must be completed within 30 days of beginning services for a public employer after January 7, 2013. It consists of three main sections: personal information, public employer information, and an acknowledgment section detailing the contractor's classification status.
The form outlines eight specific criteria that define an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including being party to a bilateral agreement, receiving payment by contractual arrangement, ineligibility for workers' compensation and employee benefits, providing own supplies and equipment, and receiving IRS Form 1099. The document emphasizes that independent contractors are not eligible for OPERS contributions and explains the process for requesting classification determinations, which must be made within five years of service commencement. The form must be retained by the public employer with a copy sent to OPERS, and failure to retain this acknowledgment may extend the contractor's right to request classification determination beyond the standard five-year period.
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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)
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 .