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Donnoe & Associates 12/30/2019
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Donnoe & Associates 12/30/2019
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Last modified
12/31/2019 9:49:12 AM
Creation date
12/31/2019 9:48:52 AM
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Contracts
Contractor's Name
Donnoe & Associates
Approval Date
12/30/2019
End Date
12/31/2020
Department
Human Resources
Department Project Manager
Michael Duerr
Subject / Project Title
Test Development Services
Tracking Number
0002144
Total Compensation
$30,000.00
Contract Type
Agreement
Contract Subtype
Professional Services
Retention Period
6 Years Then Destroy
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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 Provider have twenty-five(25)or more employees? 0 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 Syr(TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes [ 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)? ❑ Yes ❑ 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(TRS) or Law Enforcement Officers <br /> and Fire Fighters plan(LEOFF)? ❑ Yes 0 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)? 0 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 S tem(TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes No <br /> IF THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 O <br /> R 3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE FROM HR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITH THE CONTRACT. <br /> Service Provider Name: O IJ N O-C `F' /t 550 C I Pc i ES, i\IC- . <br /> Signature. / Printed Name: 1 ft.�E �oa�eTitle: CA.%F' F�6115\000\4— o�r�l C - <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />
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