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STATE RETIREMENT SYSTEMS FORM
<br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT
<br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM
<br /> 1. Does Service Provi de have twenty ve(25)or more employees? ❑ Yes IaTo
<br /> s
<br /> IF YEs Sly QUESTION 2, I Qr ON AND SIGN BELOW ,:,
<br /> IF NO: A,NSV ER QUEST1O1�TS A 3
<br /> ate ,n1 .( .
<br /> 2 RIf a Service Providerrz employee�w.ill perform Work under this Professionals ces Agreem nt, `.
<br /> a 1p .,e x a.ti3�re a r. J f` .^�,... i N
<br /> cud that employee a under.th`e tbl'tc°Employers'Retuement System(PERS),:School
<br /> r � r iE .r' .�. kn t f.
<br /> Employees''Retire ent System( ERS) Teachers'`Retirement Sy 'e (TRS),or Law
<br /> Enforcement Officers`anc Fire,Fighters.plan(LEOFF)2 'es Ido
<br /> Answer the,appropriate ques▪tion below for Service P,rovider's business organization:
<br /> SoleProptietcor.Did ServiceProvider recur un erthePublic Em ployers'Rent System
<br /> ( ,,z?",-)5..,Schoo Employeess'Retirement:Sy`�stem(SFR); achers'Retirement System(TRS),
<br /> r„,, ..,,-...,."..,,,,-;,-:,:;•-.....,,•,,...%,,
<br /> a t w J -•p A,y°r.e. lr ,� t ,u�»:��- ., 5... � 3 � '&z�� ,'
<br /> Lai=Enforce hent ce'rs rndFue .,','-,-/.,‘,„-,. plan(LEOFF)1 O Y'e iso
<br /> Par eishiip`1If a partner will p orm�Work unlet his, ro essional�` erviees Agi semen`., did
<br /> thatbpartner tire under�the Public Employers'Retirement System(PERS),School;Employees'
<br /> st � u,p r i - �Neo- .•4;,.,•:-.:‘,1-,,-
<br /> , > ti .
<br /> • Reti ept�ent,System.(SERB)-,Teachers''Retiremei s (TRS)o Law E forcement Officer's>
<br /> • and9Fire Fighters plea ®I ) ' kYe�s 0 N,o
<br /> }i lx A. f
<br /> yT,lmited.Liabilrty� ompa-.,,,,-..-;141„,,,,,,,,„,:t,-
<br /> y �fu`member will perform Work under tlus'Prctfession8 Serylces
<br /> Agent,didttember� tiePublrEmployer ' etiremeuttSy ):
<br /> • Schol�mp'loyees'Retire . S-steui4.sgm), eacl e 'Retirement Systsii�� )or Z aw
<br /> 4fC�7,,iabO i,, Atte C�}'i + ter$ to '(i, 'QFF `❑',YD NQ ••
<br /> r
<br /> C rporati©n. If a shl reholder willxperform Work under,t isProfessional Services greement,
<br /> did thatshareholder rete underlie Public Empl etirement System(PERS) School
<br /> h'xr_. e r s ° } J`i7'..-j"'. k."��. '"'r< Sw 1 . sv /,�
<br /> E }ploYees'T`etirement System SER�) Teachers'RetirementSystem(TRS),or�'Law
<br /> Enfo entO c�ers and:Fir▪e'F ghters plan►(LEOFF)? ❑ Yes ❑ No
<br /> ti x! yyn k ��&' d ” -x. t �" mcµ^,. c s 4�<a.t'�' '� d s "} i.sc p`k ,c
<br /> 7F ? `' A�yNSW A1�iY 'HOE. 2 QNS O.R 3;AN ►Dp,1,'1C NAL
<br /> }. 5xv>'r J 'tt 4-. .K! - �`.• * 1' 'F A u'✓Y '} 'Y+,ey,1 fw'ii FI
<br /> QU>ESTIONN A" - 9 c . `FROM HR O iE� � Ew LEb OE'T AN
<br /> Y � t
<br /> UB T , i ®,THE COQ 1 H 9 CTS 4 � k vFif
<br /> y ��k '�`x�, 'rL{# f ,, �yA�r�� �T *.
<br /> 't f ..c¢',1-; a �,i Y'�'W� 7 1 f x t
<br /> ervice PrQvid ameec h;. t`! 1 f, 3 ` S
<br /> A-:1..,.,,,'.. Y
<br /> Signature._ r_, ';::../;','--:. x .„:,..':,!;:,., „': .-1.t.4-',.. ...Printed Name '1 t1 Title.'n
<br /> (Retirement Form Approved by City Attorney's Office June 15,2014)
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