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Independent Contractor/Worker Acknowledgment <br />RQ# <br />In accordance with requirements from the Ohio Public Employees Retirement System (OPERS), Cuyahoga <br />County is required to obtain an acknowledgment of Independent Contractor Status. <br />A "Business Entity" means an entity with five or more employees that is a corporation, association, firm, <br />limited liability company, partnership, sole proprietorship, or other entity engaged in business. All individuals <br />employed by the business entity who provide personal services to the public employer are not public employees <br />for purposes of this purchase/contract. Cuyahoga County does not consider the individual/business employee/s <br />a public employee and no contributions will be made to the public employee's retirement system for the <br />services. (O.R.C. 145.036, 145.037). <br />UCompany Name (Please print formal business name clearly): <br />HAYFIELD VILLAGE <br />ffThe above company is defined as a Business Entity as described above (O.R.0 145.037) <br />❑ If the above company is NOT defined as a Business Entity as described above (O.R.0 145.037), <br />Then please complete the attached Independent Contractor form. <br />Signature: / d!�`� <br />Name (Please print clearly): RONALD C. WYNNE <br />DIRE T R OF FINAN E <br />Date: <br />(OPD 04-03-17) <br />Cuyahoga County Office of Procurement & Diversity <br />2079 East 9th Street, Cleveland, Ohio 44115, (216) 443-7200, FAX (216) 443-7206 <br />Ohio Relay Service (TTY) 1-800-750-0750 <br />