OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- Tiffin River Wildlife Area Drone Spraying
- Solicitation number
- SRC0000032902
- Issued by
- Fulton County, Ohio
About this file
This document is an Independent Contractor/Worker Acknowledgment form from 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. It requires completion within 30 days of starting service and captures essential information about the contractor, including personal details, service dates, and the public employer's information.
The form outlines specific criteria for independent contractors under Ohio Administrative Code, including being party to a bilateral agreement, being paid a fee, 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. The document emphasizes that independent contractors will not have retirement system contributions made on their behalf and explains potential implications, such as the ability to request a determination of public employee status within five years of service. The contractor must acknowledge understanding their classification and potential limitations regarding retirement benefits, medical reimbursements, and allowances.
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Other files
| File | Type | Posted |
|---|---|---|
| Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| Affirmation and Disclosure Form_3-4-22.pdf | ||
| Standard Terms and Conditions.pdf | ||
| Tiffin River Aerial Spraying OB.docx | DOCX document |
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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 .