OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000014076
- Issued by
- Belmont County, Ohio
About this file
This document is an Independent Contractor/Worker Acknowledgment form from the Ohio Public Employees Retirement System (OPERS) for individuals providing personal services to a public employer in Ohio. The form must be completed within 30 days of beginning service and includes the individual's personal information, the public employer's information, the service start and end dates, and confirmation of the individual's status as an independent contractor rather than a public employee.
The related state and local contract opportunity is for asphalt repair services at Barkcamp State Park in Belmont County, Ohio. The project requires milling the existing asphalt, installing a new asphalt base and surface, and providing final cleaning. The contract will be awarded to the lowest responsive and responsible bidder, and the project must be completed prior to December 2023. Interested bidders are encouraged to visit the site prior to submitting a response, and instructions are provided for how to view and respond to the solicitation through the Ohio|Buys procurement system.
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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 .