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STATE RETIREMENT SYSTEMS FORM. <br />ATTACHMENT TO PROFESSIONAL SERVICES AO ! MEND' <br />L SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br />1. 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, <br />If a Service Provider employee 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 (SERS), Teachers' Retirement System (TRS), or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? Yes 1 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 (SERE), Teachers' Retirement System (TRS), <br />Law Enforcement Officers and Fire Fighters plan (LEOFF)? 1111 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)? [1 Yes i 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 ('IRS) or Law <br />Enforeelnent Officers and Fire Fighters plan (LEOFF)? Yes ; , 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)? Yes fl No <br />IF THERE IS A "YES" ANSWER TO ANY PART OF Q,,ESTIONS 2 OR 33 AN ADDITTONAL <br />QTTJESTIONNA: + (AVAIL. LE FROM ER OR L EGATh) MUST 1E F!(1! LEI) OUT AND <br />SUBMITTED WITH THE CONTRACT. <br />Service Provider Naive: <br />c <br />Signature: <br />°Mirk ) 2-NC <br />kb?0 MtVmwnE,eHoiesr <br />Printed Naive: Title; <br />(Retirement Form Approved by City Attorney's Office June 15, 2014) <br />