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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 /> I. Does Service Provider have twenty-five(25)or more employees?.[] Yes ® 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 perform Work under this Professional Services Agreement, <br /> did that employee retie 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 /> 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)? 0 Yes ❑ 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:Offrcers and Fire Fighters plan(LEOFF)? ❑ Yes ® No <br /> shareholder will erform Work under this Professional Services Agreement, <br /> Corporation. I f a shay p...:.:.. .:... .. .. .. <br /> E <br /> �p . ..that Em t shareholder retire under the Public oy ors';:Retirement System(PERS),School:::: ' . <br /> Employees'!:Retirement System(SERS),Teachers'Retir ernent System(TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes. .❑'No . <br /> THFRE:IS A"YES"ANSWER TO ANY PART OF. QUESTIONS.2,OR 3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE FROM HR OR LEGAL)MUST BE '1LLED OUT AND. <br /> SUBMITTED WITH _kw CONTRACT.. <br /> Service Provider Name: Caliber Security:Partners LLC :: <br /> Pierce <br /> Signature: "' Printed Name: Tab Title: President&CEO <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />