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. . <br /> STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> I. Does Service Provider have twenty-five(2.51or more employees? 4 Yes El No <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3, AND SIGN BELOW. <br /> IF NO: ANSWER QUESTIONS 2 AND 3. <br /> 2. If a Service Provider employee will perfbrm Work under this ProfessionalServices Agreement, <br /> did that ernaloyec retire under the Public EmployersRetirement System (PERS), School <br /> Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br /> Enfbrcement Officers and Fire Fighters plan (LEOFF)? rj Yes -lgeNo <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 /> , <br /> Law Enforcement Officers and Fire Fighters plan (LEOFF)? [I] Yes 0 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)? n Yes L.1 No <br /> Lintited_Kiability Company. If a member will pertbrm Work under this Professional Services <br /> Agreement, did that member retire under the Public Employers' Retirement System (PERS), <br /> School Employees' Retirement System (SERS),'leachers' Retirement System (TRS)or Law <br /> Enforcement Officers and Fire Fighters plan (LEOFF)? L Yes 0 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)? [1] Yes El No. <br /> IF THERE IS A "YES" ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE FROM HR OR LECAL) MUST 1W FILLED OUT ANI) <br /> SUBMITTED WITH THE CONTRACT. <br /> Service Provider Name:, <br /> Signature: 7P-rt(315tk-e1/4----- Printed Name: Ii rilofIn,1 Bou.,e-hitic: Pre <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />