OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000016294
- Issued by
- Muskingum County, Ohio
About this file
The document is an Independent Contractor/Worker Acknowledgment form for the Ohio Public Employees Retirement System (OPERS). This form is to be completed by individuals who begin providing personal services to a public employer in Ohio on or after January 7, 2013, but are not considered public employees, such as independent contractors. The form requires the individual to provide their personal information, the name of the public employer they are providing services to, the start and end dates of the service, and an acknowledgment that they are not an OPERS or other retirement system benefit recipient.
The related state and local contract opportunity is for a 9' flatbed, 60" CA, gooseneck hitch to be installed on a 2023 Ford F550 cab and chassis. The specifications include a steel or aluminum bed, full-length sills, tapered bulkhead, LED lights, side rails with stake pockets, a receiver tube, and toolboxes. The contract is for the bed and added equipment only, to be installed at the vendor's place of business, which must be within 75 miles of the Blue Rock State Forest in Ohio. Delivery is to be made to 6665 Cutler Lake Rd, Blue Rock, Ohio 43720.
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Other files
| File | Type | Posted |
|---|---|---|
| Services Agreement (Non-Federal Funds) Base Template_Rev. 2023 04 11.docx | DOCX document | |
| BRSF F550 Bed Specs.pdf | ||
| Standard_T_C_04-10-23.pdf | ||
| Standard Affirmation & Disclosure Form_fillable PDF Form.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 .