OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000034419
- Issued by
- Darke 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 providing personal services to a public employer on or after January 7, 2013, who are classified as independent contractors and will not have contributions made to OPERS. The form must be completed within 30 days of beginning service and requires detailed information about the contractor's personal details and the public employer.
The document outlines the specific definitions and requirements for independent contractors under Ohio Administrative Code, including key characteristics such as being party to a bilateral agreement, being paid a fee, not being eligible for employee benefits, not appearing on a public employer's payroll, and providing their own supplies and equipment. The form emphasizes that independent contractors are not public employees and will not be contributors to the retirement system, with potential implications for medical reimbursement and retirement benefits. Contractors are advised of their right to request a determination of their employment classification and the potential consequences of their current classification.
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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 .