OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000013335
- Issued by
- Jefferson County, Ohio
About this file
This document is an OPERS Independent Contractor/Worker Acknowledgment form to be completed by individuals providing personal services to a public employer in Ohio. The form must be submitted within 30 days of starting service, and includes the individual's personal information, the public employer's information, and the dates of service provided.
The related state and local contract opportunity is for the replacement of 300 feet of asphalt on a roadway at Lake Alma State Park in Wellston, Ohio. The project requires milling the existing 2-inch asphalt, cleaning the area, applying tack, and installing and compacting 2 inches of new #448 asphalt surface material. The contract will be awarded to the lowest responsive and responsible bidder, and the work must be completed prior to June 2024. Bidders are encouraged to schedule a site visit with the park contact before submitting a bid.
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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 .