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STATE RETIREMENT SYSTEMS FORM <br />M <br />A A TA CEMENT TO PROFESSIONAL SERVICES AGREEMENT <br />ALL SERVICE I CE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br />1, Toes Service Provider have twentvnfive (25) or more employees? n Yes 1 No <br />IF YES: SKIP QUESTION 2, SKIP QUESTION 3, AND SIGN BELOW. <br />W NO: ANSWER QUESTIONS 2 AND 3. <br />2. If a Service Provider ernplavee 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 (SERE), Teachers' Retirement System (11(S), or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? 0 Yes 0 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)? J Yes 0 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 fl No <br />Limited Liability Company. If a member will perform Work ender 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)? Yes NI 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 ORS), or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? ] Yes D No <br />4 <br />1 <br />IF THERE IS A "YES» ANSWER R TO A t it( PART OF QUESTIONS 2 OR 3, AN ADDITIONAL <br />QUESTIONNAIRE (AVA]ELABLE FRS 1 IIR Olt LEGAL) MUST BE FILMED OUT AND <br />SUBMITTED WIT c,ti THE CONTRIAT. <br />Service Provider Name: Bush, o iltchlf'1 �, Inc. <br />• <br />Signature: <br />ture: <br />• <br />PrintedName: Dakin Bell Title; Principal <br />(Retirement Form Approved by City Attorney's Office Juno 15, 2014) <br />