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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 haystwenty-five(25)or more employees? ®:`Yes.y❑ No: <br /> IF YES; SKIP QUESTION 2,SKIP QUESTION 3,ANIS:SIGN BELOW <br /> IF NO•ANSWER.QUESTIONS;2'AND 3 <br /> aSir 'ice Provider employee will'performz Work under flus Profess or al Services <br /> Agreement, did that erriployee:retire under:the Public Employers'RetirementSystem <br /> School Employees'Retirement System(SERB);.or Teachers'Retirem{ ent= <br /> System(TRS) :❑ Yes 111.1m.No = <br /> 3 =Answer the a1ipropr ate.question below for:Service Provider's business organization <br /> Sole Proprietor .Did Service Provider retire under_the Public Emp•loyers' Retirement <br /> System(PERS), School.Employees'Retirement System($ERB),or Teachers' <br /> Retirement;System (TRS) ❑ Yes ❑ No <br /> Partnership. If.a partner-;will perform Work underalus Professional Services <br /> Agreement,_did thatpartner retire:under the Public Employers'Retirement System <br /> (PERS),School Rinployees' Retirement System(SERB);:or Teachers.'.Retirement..; <br /> =SSystem(TRS)? ❑ Yes 0 No:: <br /> Lunited I iabm hty.Company :If a member will perform-Work under ti s Professional <br /> • Services-Agreement;did:thatmembei retire'under the.Publ�c Employe•s' Retirement • <br /> System(PERS), School Employees':Retirement System(SERB), or Teachers' <br /> Retirement:System(TRS)? ❑:Yes-❑ No <br /> Corporation: If a shareholderwill perform VYork under this Professional Service•s <br /> Agreement;'didthat:shareholder retire;wider the Public Employers'Retirement System ' <br /> (PERS) School Erriployees'Retirement System(SERB); or.Teachers'Retirement <br /> System(TRS) ❑ Yes.:. ❑ No <br /> Service Provider Name: DLR:Group, me (a Washington Corporation) <br /> S ervice Provider Phone:Number: 206/461-6000 <br /> Si afore �_ Printed Name:UV: Valdez Title:VP',Principal.: <br /> (Retirement Form Approved by City Attorney's Office January 1,2010) <br /> 48 <br />