OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000022229
- Issued by
- Fairfield 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, but who are not considered public employees. The form requires the individual to provide personal information, the name of the public employer they are providing services for, the start and end dates of the service, and acknowledgment that they are not an OPERS or other retirement system benefit recipient. The related state and local contract opportunity is for aquatic herbicide spraying services at various fishing and boating access areas in Northwest Ohio, to be performed for the Ohio Department of Natural Resources (ODNR) during Fiscal Year 2025. The contractor will be responsible for twice-yearly spraying at eight designated locations, including the use of approved herbicides, compliance with regulations, and coordination with private property owners.
The contract will be awarded based on the contractor's proposed pricing, which must detail the types, brands, and amounts of materials to be used. The initial spraying is scheduled for late August 2024, and the second for May 2025. The contracting documents do not specify any set-aside designations or restrictions on the types of organizations that can respond, nor do they indicate any incumbent vendors or current contractors, or any existing infrastructure or technology that requires integration. The Scope of Work details the locations and frequency of the required services, but does not include any listed award values or budget ranges for this state and local contract opportunity.
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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 .