OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- FY26 - District 2 Fish Access Area Vegetation Control State and local contract opportunity
- Solicitation number
- SRC0000032462
- Issued by
- Lucas County, Ohio
About this file
This document is an OPERS (Ohio Public Employees Retirement System) 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 must be completed within 30 days of beginning service and is used to formally document an independent contractor's status and understanding that no retirement system contributions will be made for their services.
The form requires detailed information including personal details, public employer information, service dates, and a comprehensive acknowledgment section explaining the contractor's classification. Key provisions include defining an independent contractor under Ohio Administrative Code, noting that the contractor is not eligible for workers' compensation, employee benefits, or public employer payroll, and must provide their own supplies and equipment. The document also outlines potential implications, such as the ability to request a determination of employment status within five years and potential liability for retirement system and medical account reimbursements based on the contractor's classification.
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| Affirmation and Disclosure Form_3-4-22.pdf | ||
| Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| Scope of work for herbicide spraying-FY26.pdf | ||
| Standard Terms and Conditions.pdf |
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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 .