Laserfiche WebLink
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? [ZI Yes 0 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 retire under the Public Employers' Retirement System (PERS), School <br />Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br />Enforcement Officers cers and Fire Fighters plan (LEOFF)? Q 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)? 0 Yes [1 No <br />partner Partnership. If will perform Work under this Professional Services Agreement, did <br />that partner retire under the Public Employers' Retirement System (PERS), School Employees' <br />Retirement .ment System (SERS), Teachers' Retirement System (TRS) or Law Enforcement Officers <br />and Fire Fighters plan (LEOFF)? ■ Yes 0 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 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 ► No <br />IF TARE IS A "YES" ANSWER TO ANY PART OF QUESTIONS 2 OR 3, AN ADDITIONAL <br />QUESTIONNAIRE AVAILABLE FROM FIR OR LEGAL) MIST BE FILLED OUT AND <br />SUBMITTED WITH THE CONTRACT. <br />Service Provider Name: QaJtca SW" �t�.U� rtA �T.%Ne.C.r "R� SCr eA S .tc,, <br />Signature: <br />Printed Name: gAnct\ STICA"co.k.) Title: Vert c <br />1 <br />(Retirement Form Approved by City Attorney's Office June 15, 2014) <br />