OPERS_Independent_Contractor_Form_fillable_PDF_Form.pdf
PDF 229 KB Posted
- Solicitation number
- SRC0000028692
- Issued by
- Fairfield County, Ohio
About this file
The file is an OPERS Independent Contractor/Worker Acknowledgment form from the Ohio Public Employees Retirement System (OPERS), located in Columbus, Ohio. This document is specifically designed for individuals providing personal services to a public employer on or after January 7, 2013, who are classified as independent contractors and will not have retirement contributions made on their behalf. The form must be completed within 30 days of beginning service to the public employer.
The form requires detailed personal information including Social Security Number, date of birth, name, and employer details, as well as specific service information such as the name of the public employer, contact information, service start and end dates, and whether the individual is currently a retirement system benefit recipient. The document serves as an official acknowledgment and documentation mechanism for independent contractors working with public employers in Ohio, ensuring proper classification and retirement system compliance.
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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 .