OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- Oxbow Lake Boat Dock Refurbishment State and local contract opportunity
- Solicitation number
- SRC0000034412
- Issued by
- Delaware 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 individual's personal details, current employer, and the public employer for whom services are being provided.
The document outlines the specific criteria for an independent contractor under Ohio Administrative Code, including being party to a bilateral agreement, being paid a fee or retainer, not being eligible for workers' compensation, not appearing on a public employer's payroll, and providing their own supplies and equipment. The form emphasizes that the independent contractor is not a public employee and will not receive retirement system contributions. It also includes important acknowledgments about potential eligibility for medical reimbursements, the possibility of requesting a determination of employment status, and potential liability for incorrect classification or receipt of benefits.
View the file
Other files for this state and local contract opportunity
| File | Type | Posted |
|---|---|---|
| Ohio Buys Quote Scope for Dock redecking.pdf | ||
| Addendum to Bid Quote Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| Affirmation and Disclosure Form_3-4-22.pdf | ||
| Services Agreement Template (Non-Federal Funds)_for OhioBuys.docx | DOCX document | |
| 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 .