OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000026707
- Issued by
- Clermont County, Ohio
About this file
This file is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form used for individuals providing personal services to public employers in Ohio. The form must be completed within 30 days of beginning services for individuals who start providing personal services to a public employer on or after January 7, 2013, but are not considered public employees and will not have OPERS contributions made on their behalf. The document includes sections for personal information, public employer details, and service dates.
The form outlines eight specific criteria defining an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including requirements about bilateral agreements, payment arrangements, and ineligibility for various benefits. It clarifies that independent contractors cannot be OPERS contributors and provides information about requesting determinations of public employee status within five years of service commencement. The form must be retained by the public employer with a copy sent to OPERS, and failure to retain this acknowledgment may extend the contractor's right to request a determination beyond the standard five-year period. The document also includes provisions regarding retiree medical benefits and potential liability for incorrectly paid benefits.
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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 .