Michael McCarthy 9/3/2019 - Laserfiche WebLink

s STATE RETIREMENT SYSTEMS FORM ATTACHMENT TO PERSONAL SERVICES CONTRACT THE HEARING EXAMINER PRO TEM MUST COMPLETE AND SIGN THIS FORM 1. Does the I- aring Examiner Pro Tern have twenty-five(25) or more employees? ❑ Yes o IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW, IF NO: ANSWER QUESTIONS 2 AND 3. 2. If a Hearing Examiner Pro Tern employee will perform services under this Contract,did that em.•to ee retire under the Public Employers' Retirement System(PERS), School Employe • Retirement System(SERS),or Teachers' Retirement System(TRS)? ❑ Yes ' No 3. Answer the appropriate question below for the Hearing Examiner Pro Tern's business organization: Sole Proprietor. Did the Hearing Examiner Pro Tern re. under the Public Employers' Retirement System(PERS), School Employees' Ret ement System(SERS), or Teachers'Retirement.System(TRS)? _ Yes el .No Partnership. If a partner will perform services under this Contract, did that partner retir Under th Public Employers' Retirement System(PERS),School Einployees' Retire, 'ent System.(SERS), or Teachers'Retirement System(TRS)? ❑ Yes No Limited Liability,Company. I.f a member will perform services under this Contract,did that menu er retire under the Public Employers' Retirement System(PERS), School Employ es' Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ Yes ' No Corporation. If a shareholder will perform services under this Contract, did that shareholder retire under the Public Employers' Retirement System(PERS), School i. Employee ' Retirement System(SERS),or Teachers' Retirement System (TRS)? ❑ Yes /No Hearing Examiner Pro Tern Name: a a /11,C(14r Hearing Examine P-. • em P`•ne Number: .2,-5-3 j 27 2 2 Signature: r� _ Printed Name:/(!�edWi(,� /T�Itle: 410/2 , ,' ,— i Hearing Examiner Pro Tern Contract 2019 Page 6 of 6