OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000020923
- Issued by
- Seneca County, Ohio
About this file
The document is an independent contractor/worker acknowledgment form from the Ohio Public Employees Retirement System (OPERS). It is to be completed by individuals who begin providing personal services to a public employer in Ohio on or after January 7, 2013, but are not considered public employees, such as independent contractors. The form must be submitted within 30 days of beginning the service provision. The document includes sections for the individual's personal information and the public employer information, such as the start and end dates of the service provided.
The related state and local contract opportunity is for water well drilling services at the Willow Point Wildlife Area in Ohio. The Ohio Department of Natural Resources, Division of Wildlife is soliciting bids for this work, which includes mobilization, site clearing and grading, well installation, and development of an 8" PVC water well. Mandatory site visits are required between June 3-14, 2024, and the contract will be awarded to the lowest responsive and responsible bidder. The State of Ohio requires the use of Ohio-certified Minority Business Enterprises (MBE) and Encouraging Diversity, Growth and Equity (EDGE) vendors where applicable. The total contract value is not to exceed a specified amount, and the contract term is through the end of the current biennium.
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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 .