Opers Form Ped 1Ee – Fill Out and Use This PDF

Ohio Public Employees Retirement System

277 East Town Street, Columbus, Ohio 43215-4642	*PED-1ER*
1-800-222-PERS (7377) www.opers.org

Independent Contractor/Employee Determination for Worker

(To be completed independently by the worker)

This form is used by OPERS to obtain information to determine whether a worker is a public employee for purposes of state retirement law. OPERS recognizes while questions in this form are asked in the past tense, you may be providing information on present service.

Complete this form in its entirety, sign and date it, and submit it directly to OPERS at the above address. Any supporting documentation should accompany this form. The employer will complete and submit an Independent Contractor/Employee Determination for Employer (PED-1ER) that asks for similar information.

Section 1 - Personal Information

Social Security Number

First Name

MI Last Name

Street or Mailing Address

Apt. Number

City

State

ZIP Code

-

Home Phone Number

Work Phone Number

Cell Phone Number

E-mail Address

Section 2 - Employment Information

This inquiry concerns service as:

Title or Position

Employer

Month Day

Year

Month

Day

Year

From

To

Employer Contact - First Name

MI

Last Name

Employer Contact - Work Phone Number

Title or Position of Employer Contact at Time of Service

1. Does a public entity or statute authorize this position?

Yes

No “If “Yes,” state the public entity or statute.

2.State your job title as it existed at the time of service. Attach a copy of the job description/classification.

3.At the time you performed services for the employer, did you perform the same or similar services for other employees? Yes No If “Yes,” list other public employers.

PED-1EE (Revised 6/12)

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Section 2 - Employment Information continued

4.How were the compensation, rights, obligations, benefits, and responsibilities for this position established? Mark all that apply and attach copies. Copies must be attached for consideration in membership determination.

Contract			Ordinance			Court Entry		Charter
Statute			Resolution			Board Minutes		Memorandum of Understanding
Other	Describe: ___________________________________________________________________________________
							Month Day		Year

If you are no longer performing this job, please provide the date services terminated.

5.Did the above specifically address the your right to receive OPERS benefits? Yes No

6.Were you required to have a set schedule? Yes No

Please describe how your schedule was set: ________________________________________________________________

__________________________________________________________________________________________________________

Who was responsible for service coverage if you were unavailable? Employer You

7.Did you work on a specific project? Yes No

If yes, please explain: ______________________________________________________________________________________

__________________________________________________________________________________________________________

8. Were you working on the job for a defined period of time or until a specific project was completed?

Yes

No

If yes, please explain: ______________________________________________________________________________________

__________________________________________________________________________________________________________

9.Did the employer provide you dedicated office space? Yes No

If yes, please explain: ______________________________________________________________________________________

__________________________________________________________________________________________________________

Did the employer provide office equipment and supplies (i.e. computer, office furniture)		Yes		No

If yes, please explain: ______________________________________________________________________________________

__________________________________________________________________________________________________________

10.To whom were you accountable for reporting progress and completion of assignments?

__________________________________________________________________________________________________________

How often did you report progress? __________________________________________________________________________

How did you report progress and what information was included in the progress report?

__________________________________________________________________________________________________________

What were the consequences of deficient work? _______________________________________________________________

11. Did you follow employer’s procedures as outlined in an employee manual or handbook?

Yes

No

12. Were you permitted to (Check all that apply):
		Delegate duties to other public employees working for the employer		Hire assistants
		Supervise other public employees working for the employer		Subcontract work

PED-1EE (Revised 6/12)

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Section 2 - Service Information for law solicitors, law directors and prosecuting attorneys, etc.

This Section is to be completed ONLY if the worker was performing services as a law solicitor, law director, prosecuting attorney, assistant law solicitor, assistant director or assistant prosecuting attorney. Otherwise, go to Section 4 to complete the form.

1.How were you paid?

Salary

Retainer

Hourly rate

Salary and hourly rate

If applicable, please explain what work is paid on a retainer basis and/or what work is paid on an hourly basis. Attach a separate sheet if necessary: _________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

2. Did you alone perform the services?					Yes		No
Did other member’s of the worker’s law firm (e.g. attorneys, paralegals, secretaries) perform any duties related to this
service?		Yes		No If “Yes,” please explain: ____________________________________________________________

__________________________________________________________________________________________________________

__________________________________________________________________________________________________________

Who paid these members of your law firm?_____________________________________________________________________

Did other attorneys, other than members of your law firm, perform these services?

Yes

No

If “Yes,” please explain: ____________________________________________________________________________________

__________________________________________________________________________________________________________

Section 3 - Worker Certification

I hereby certify that the statements, as set forth in this document, are true and accurate.

Month Day Year

Worker’s Signature_________________________________________________________________

PED-1EE (Revised 6/12)

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