OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000022034
- Issued by
- Wayne County, Ohio
About this file
This document is an OPERS Independent Contractor/Worker Acknowledgment form to be completed by an individual providing personal services to a public employer in Ohio on or after January 7, 2013, but who is not considered a public employee. The form requires the individual to provide their personal information, the public employer's information, and the details of the services being provided, including the start and end dates.
The related state and local contract opportunity is for the replacement of deck boards on several fishing docks located in Williams and Defiance Counties, Ohio. The project involves removing the existing wood, rub rails, and cleats, and installing new composite decking boards in a Pebble Gray or Winchester Gray color, secured to treated lumber frames. The new decking must be installed with hidden fasteners and framed along all edges with treated lumber. The docks will remain in the water, but the contractor may choose to remove them if preferred, and a crane will be required. No specific pricing terms, set asides, incumbents, funding requirements, or other salient information is provided.
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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 .