OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000037126
- Issued by
- Putnam County, Ohio
About this file
This is an independent contractor acknowledgment form issued by the Ohio Public Employees Retirement System (OPERS) for individuals providing personal services to Ohio public employers who are not classified as public employees and will not receive OPERS contributions. The form must be completed within 30 days of beginning service and requires the contractor to provide personal information including Social Security number and date of birth in Step 1, followed by details about the public employer and service arrangement in Step 2, including employer name and contact information, employer code, phone number, service description, and service start and end dates.
The form serves as documentation that the service provider is classified as an independent contractor rather than a public employee and therefore will not participate in the OPERS retirement system. This acknowledgment is a mandatory administrative requirement for public employers in Ohio when engaging individuals on or after January 7, 2013 in non-employee capacities. The form does not address compensation terms, insurance requirements, or project-specific deliverables; rather, it functions solely as a classification and acknowledgment document within Ohio's public employee retirement system framework.
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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 .