OPERS Independent Contractor Form_fillable PDF Form (9).pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000028411
- Issued by
- Hocking County, Ohio
About this file
This document is an Independent Contractor/Worker Acknowledgment form issued by the Ohio Public Employees Retirement System (OPERS), located in Columbus, Ohio. The form is designed for individuals who begin providing personal services to a public employer on or after January 7, 2013, but are not considered public employees (such as independent contractors). The form must be completed within 30 days of beginning service and documents the details of the independent contractor's engagement, including personal information, public employer details, service dates, and an acknowledgment of their classification.
The form clarifies that as an independent contractor, the individual will not have retirement system contributions made on their behalf, is paid by fee or contractual arrangement, is not eligible for employee benefits, does not appear on the public employer's payroll, and must provide their own supplies and equipment. The document outlines potential implications, such as the ability to request a determination of employment status within five years, and warns that incorrectly classified contractors may be liable to the retirement system for various financial considerations. The form requires the contractor's signature and serves as a legal acknowledgment of their independent contractor status.
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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 .