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I <br /> i <br /> i <br /> 1 <br /> I <br /> STATE RETIREMENT SYSTEMS FORM '• <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM s <br /> t <br /> S <br /> E <br /> 1 <br /> E <br /> I. Does Service Provider have twenty-five(25)or more employees? © Yes El No <br /> IF YES: SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BELOW. 1 <br /> IF NO:ANSWER QUESTIONS 2 AND 3. l <br /> 2. If a Service Provider employee will perform Work under this Professional Services Agreement, g <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)? ❑Yes ❑ No <br /> 1 <br /> E <br /> i <br /> 3. Answer the appropriate question below for Service Provider's business organization: 1 <br /> i <br /> I <br /> Sole Proprietor. Did Service Provider retire under the Public Employers'Retirement System E <br /> (PERS),School Employees'Retirement System(SERS),Teachers'Retirement System(TRS), 2 <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes❑ No 1 <br /> i <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(TRS)or Law Enforcement Officers i <br /> and Fire Fighters plan(LEOFF)? El Yes ❑ No <br /> r <br /> 4 <br /> Limited Liability Company. If a member will perform Work under this Professional Services <br /> 11 <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 I <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No <br /> I <br /> 1 <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 f <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No <br /> IF THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE FROM HR OR LEGAL)MUST BE FILLED OUT AND I <br /> SUBMITTED WITH THE CONTRACT. <br /> n <br /> Service Provider Name: Skyhawks Sports Academy 1 <br /> i <br /> J^ 7 <br /> 6Signature: Printed Name: Jason Frazier Title: Prestdent t <br /> I <br /> 1 <br /> l <br /> (Retirement Form Approved by City Attorney's Office June 15,201 4) <br /> i <br /> t <br /> 1 <br />