OPERS Independent Contractor Form_fillable PDF Form (7).pdf

PDF 227 KB Posted

Attached to
Adaptive Management of Phragmites in Old Woman Creek NERR
Solicitation number
SRC0000032784
Issued by
Fairfield 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 on or after January 7, 2013, who are not considered public employees. The form requires independent contractors to acknowledge their classification and understand that no retirement system contributions will be made on their behalf. It must be completed within 30 days of beginning service to the public employer.

The form outlines specific criteria for independent contractor status, including being paid by fee or 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 income tax reporting. The document emphasizes that independent contractors are not public employees and explains potential implications, such as ineligibility for certain medical accounts and retiree benefits. Contractors must acknowledge the classification and understand their rights to request a determination of their employment status within specific timeframes.

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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 .