Laserfiche WebLink
0 <br /> STATE RETLREMENT SYS 1`J MS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> 1. Does Service Provider have twenty-five(25)or more employees? [ Yes No <br /> IF YES:SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BELO . <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> 2. If a Service Provider employee will perform Work under this Professional Services Agreement, <br /> did that employee retire under the Public Employers'Retirement System(PERS), School <br /> Employees'Retirement System(SERS),Teachers' Retirement System(TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? n Yes C No <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> Sole Proprietor. Did Service Provider retire under the Public Employers'Retirement System <br /> (PERS),School Employees'Retirement System(SERS),Teachers'Retirement System(TRS), <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? I I Yes n No <br /> Partnership. If a partner will perform Work under this Professional Services Agreement,did <br /> that partner retire under the Public Employers'Retirement System(PERS),School Employees' <br /> Retirement System(SERS),Teachers'Retirement System(IRS)or Law Enforcement Officers <br /> and Fire Fighters plan(LEO± O? ❑ Yes ❑ No <br /> Limited Liability Company. If a member will perform Work under this Professional Services <br /> Agreement,did that member retire under the Public Employers'Retirement System(PERS), <br /> School Employees'Retirement System(SERS),Teachers' Retirement System(TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? n Yes [ No <br /> Corporation. If a shareholder will perform Work under this Professional Services Agreement, <br /> did that shareholder retire under the Public Employers'Retirement System(PERS),School <br /> Employees'Retirement System(SERS),Teachers'Retirement System(TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No <br /> IF TN IRE IS A"YES"ANSWER TO ANY PART OF FROM HR R LEGAL)STIONS 2 OR 3,AN ML7S BE FILLED OUT ANQUESTIONNAIRE <br /> SUBMITTED WITH THE CONTRACT. <br /> RACT. ,� /� <br /> Service Provider Nam e:(1 7 " five �''k <br /> Signa JJ <br /> �/ J e Printed Namtf )Title: re, <br /> (Retirement Form pproved by City Attorney's Office June 15,2014) <br />