OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000027612
- Issued by
- Erie County, Ohio
About this file
This is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form used for individuals providing personal services to public employers in Ohio who are not considered public employees. The form must be completed within 30 days after beginning services for any public employer on or after January 7, 2013. The form is designed to document that these individuals will not have contributions made to OPERS.
The form requires personal information including Social Security Number, date of birth, name, and current employer details. It also requires public employer information such as the name of the public employer, employer contact information, employer code, and the start and end dates of service. The form includes a checkbox for individuals who are OPERS or other retirement system benefit recipients.
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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 .