OPERS Independent Contractor Form_fillable PDF Form.pdfOPERS Independent Contractor Form_fillable PDF Form.pdf
PDF 249 KB Posted
- Solicitation number
- SRC0000041239
- Issued by
- Ohio
About this file
This is an OPERS Independent Contractor/Worker Acknowledgment Form issued by the Ohio Public Employees Retirement System (OPERS), a state retirement system agency. The form is required for individuals who begin providing personal services to Ohio public employers on or after January 7, 2013, but are not classified as public employees and will not have contributions made to OPERS. The form must be completed within 30 days of beginning service with the public employer. The document requests personal information from the contractor, including social security number and date of birth, as well as details about the public employer and the services being provided, including start and end dates of service.
The form serves as an acknowledgment that the service provider is an independent contractor or worker rather than a classified public employee subject to OPERS retirement contributions. This classification affects retirement benefits and employment status under Ohio's public retirement system. The form is fillable and was last revised in June 2017. Contractors and public employers can obtain additional information through OPERS Employer Services at 1-888-400-0965 or at www.opers.org.
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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 .