OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- Magee Marsh WA Network & Connectivity Upgrade
- Solicitation number
- SRC0000018683
- Issued by
- Preble County, Ohio
About this file
The document is an OPERS Independent Contractor/Worker Acknowledgment form to be completed by individuals providing personal services to a public employer in Ohio on or after January 7, 2013, who are not considered public employees. The form requires the independent contractor to provide personal information, details about the public employer and the services being provided, as well as the start and end dates of the service period.
The related state and local contract opportunity is for a network and connectivity upgrade at the Magee Marsh Wildlife Area in Ohio. The contract will be awarded to the lowest responsive and responsible bidder. Mandatory site visits are available by appointment on specific dates, and the awarded supplier will be required to sign an Addendum to Bid Quote or Personal Services Agreement. All bidders must sign and attach the Standard Affirmation & Disclosure Form to their bid in Ohio Buys.
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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 .