OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Attached to
- Willow Grove Cross Ripping 2025
- Solicitation number
- SRC0000027125
- Issued by
- Belmont County, Ohio
About this file
This is an Independent Contractor/Worker Acknowledgment form from the Ohio Public Employees Retirement System (OPERS) that must be completed by individuals providing personal services to public employers who are classified as independent contractors rather than public employees. The form must be submitted within 30 days of beginning services and includes sections for personal information, public employer details, and acknowledgment of independent contractor status.
The form outlines eight specific criteria defining an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including requirements such as being party to a bilateral agreement, receiving payment through contractual arrangement, ineligibility for workers' compensation and benefits, providing own supplies/equipment, and receiving IRS Form 1099. The document explicitly states that independent contractors are not eligible for OPERS contributions but retain the right to request a determination of eligibility within five years of service start date. The form must be retained by the public employer with a copy sent to OPERS, and failure to maintain this acknowledgment may extend the contractor's right to request status determination beyond the standard five-year period.
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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 .