OPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000028242
- Issued by
- Putnam County, Ohio
About this file
This is an Ohio Public Employees Retirement System (OPERS) Independent Contractor/Worker Acknowledgment form used when an individual begins providing personal services to a public employer on or after January 7, 2013, but is not considered a public employee. The form must be completed within 30 days of beginning services and requires personal information, current employer details, and public employer information including service dates and contact information.
The form outlines eight specific criteria that define an independent contractor under Ohio Administrative Code section 145-1-42(A)(2), including being paid by contractual arrangement, not being eligible for workers' compensation or benefits, providing own supplies, and receiving an IRS Form 1099. The document clarifies that independent contractors are not public employees and cannot contribute to OPERS, though they may request an eligibility determination within five years of beginning services. 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 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 .