OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000023232
- Issued by
- Wayne 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 on or after January 7, 2013 but are not considered public employees, such as independent contractors. The form must be completed within 30 days of beginning the service to the public employer, and it requires the individual to provide their personal information, the name of the public employer, the type of service provided, and the start and end dates of the service.
The document outlines the requirements for individuals who are not considered public employees to acknowledge their independent contractor or worker status and their understanding that contributions will not be made to OPERS on their behalf. It is a standardized form used to collect this information across public employers in Ohio.
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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 .