OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- Hocking Hills State Park - Water Well Service
- Solicitation number
- SRC0000012500
- Issued by
- Hocking County, Ohio
About this file
The document is an Independent Contractor/Worker Acknowledgment form from the Ohio Public Employees Retirement System (OPERS) related to a state and local contract opportunity for water well service at Hocking Hills State Park in Hocking County, Ohio. The scope of work includes mobilizing and demobilizing equipment, removing and reinstalling the pump, piping, and wire, inspecting the well with a video camera, cleaning the well to restore adequate water flow, extending the casing if needed, flushing and chlorinating the well, and completing all necessary cleanup and permitting. The contract will be awarded to the lowest responsive and responsible bidder, and the successful contractor must complete the work within 30 days of the purchase order issuance. Bidders are encouraged to conduct a site visit prior to submitting a bid response, and the contract will be awarded based on the low lot total bid price.
The pricing terms for this contract are not specified, and there are no set-asides, incumbents, or funding details provided. The contract opportunity is being handled through the state's Ohio|Buys procurement system, and bidders are advised to review the provided training materials and contact the Ohio Shared Services Help Desk with any questions or issues.
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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 .