OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000026407
- Issued by
- Seneca County, Ohio
About this file
This is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form, which must be completed by individuals providing personal services to Ohio public employers who are not classified as public employees. The form must be submitted within 30 days of beginning services and includes sections for personal information, public employer information, and acknowledgment of independent contractor status. The form was revised in June 2017 and is used to establish the worker's classification status and acknowledge that OPERS contributions will not be made on their behalf.
The form outlines eight specific criteria that define an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including requirements about bilateral agreements, payment arrangements, and ineligibility for benefits. It specifies that independent contractors cannot become contributors to the retirement system, though they may request a determination from OPERS within five years if they disagree with their classification. The form also addresses implications for OPERS Health Reimbursement Arrangement (HRA) and OPERS Retiree Medical Account (RMA) participants, noting potential liability for allowances or reimbursements if improperly classified.
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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 .