Vendor Information Pickerington (Page 4 of 4) in pdf

STEP 3: Acknowledgment

The public employer identified in Step 2 has identified you as an independent contractor or another classification other

than a public employee. Ohio law requires that you acknowledge in writing that you have been informed that the public

employer identified in Step 2 has classified you as an independent contractor or another classification other than a

public employee for the services described in Step 2 and that you have been advised that contributions to OPERS will

not be made on your behalf for these services.

If you disagree with the public employer’s classification, you may contact OPERS to request a determination as to

whether you are a public employee eligible for OPERS contributions for these services. Ohio law provides that a

request for a determination must be made within five years after you begin providing personal services to the public

employer, unless you are able to demonstrate through medical records to the Board’s satisfaction that at the time the

five-year period ended, you were physically or mentally incapacitated and unable to request a determination.

By signing this form, you are acknowledging that the public employer for whom you are providing personal services

has informed you that you have been classified as an independent contractor or another classification other than a

public employee and that no contributions will be remitted to OPERS for the personal services you provide to the

public employer. This acknowledgment will remain valid as long as you continue to provide the same services to the

same employer with no break in service regardless of whether the initial contract period is extended by any additional

agreement of the parties. You also acknowledge that you understand you have the right to request a determination of

your eligibility for OPERS membership if you disagree with the public employer’s classification.

This form must be retained by the public employer and a copy sent to OPERS. The public employer’s failure to

retain this acknowledgment may extend your right to request a determination beyond the five years referenced

above.

Signature____________________________________________________________Today’s Date_________________

Do not print or type name

PEDACKN (Revised 12/2012)

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Vendor Information Pickerington Page 4