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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? ❑ Yes [IN° <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW. <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> , <br /> 2. If!a Service Provider employee will perform Work under this Professional Services Agreement, <br /> dill that employee retire under the Public Employers' Retirement System(PERS),School <br /> Employees' Retirement System(SERS),Teachers' Retirement Syste (TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes iiiNo <br /> , <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> S le Proprietor. Did Service Provider retire under the Public Employers' Retirement System <br /> (PIERS), School Employees' Retirement System(SERS),Teachers' Reti ent System(TRS), <br /> Low Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes ME No <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 <br /> and Fire Fighters plan(LEOFF)? ❑ Yes Et 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' Retiremer ystem(TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes No <br /> C =ration. If a shareholder will perform Work under this Professional Services Agreement, <br /> di 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 erNo <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 <br /> SUBMITTED WITH THE CONTRACT. <br /> Susie Howell <br /> Service Provider Name: <br /> iS. Howell Proprietor <br /> Signature. Printed Name: Title: <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />