OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000027875
- Issued by
- Putnam County, Ohio
About this file
This document is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form, required for individuals who begin providing personal services to Ohio public employers on or after January 7, 2013, but are not considered public employees. The form must be completed within 30 days of beginning services and consists of three main sections: Personal Information, Public Employer Information, and Acknowledgment. The document outlines the service relationship between independent contractors and public employers in Ohio.
The form details eight specific criteria that define an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including contractual payment arrangements, ineligibility for benefits and workers' compensation, and requirements for self-supplied equipment. The document emphasizes that independent contractors are not eligible for OPERS contributions and have five years to request a determination of their status if they disagree with their classification. It also includes important provisions regarding retirees who return to work, noting potential implications for healthcare reimbursement arrangements (HRA) and retiree medical accounts (RMA). The form must be retained by the public employer with a copy sent to OPERS for record-keeping purposes.
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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 .