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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 />Does Service Provider have twenty-five (25) or more employees?: <br />IF.YES' SKIP. QUESTION2,:SKIP: .QUESTION 3,`AND SIONBELO . <br />IF NO: ANSWER.QU.STIONS. AND.3 ' : : . <br />If a Service Provider employee will perform.Work under this Professional. Services. Agreement <br />that emplovee retireunder the Public Erployers':Retxteru.ent System. (PEES) School _ ' <br />:Employees .Retirement System (SERS), Teachers' Retirement System (IRS), or Law. <br />Enforcement Officers and Fire Fighters plan (LEOFF)? ❑ Yes - <br />Answer the appropriate questionbelow :Provider'_sbusiness..organizatiori: <br />Sole Proprietor : Did Service Provider retire under the Public Employers'. Retirement System .::. <br />(PERS), School Employees''. Retirement System (SERS), Teachers'.Retirement.System. (1RS), <br />Law Enforcement Officers and Fire Fighters plan (LEOFF)? . L Yes ❑ No <br />Partnership.:If a partner will, perform Woris under this Professional: Services Agreement, di...:.:'.:. <br />that partner retire under the Public Employers' Retirement System (PEES), School Employees': <br />Retirement System .(SERS), Teachers'.. Retirement, System .(TRS).or Law Enfoicement Officers <br />and Fire Fighters .lan.(LEOFF)?i `:Yes <br />% Limited Liability Company.:`If a.mnemberwill perfonn Worktinder .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. Systerri (TRS) or Lavy <br />Enforcement Officers and Fire Fighters plan (LEOFF)? ® Yes j-j No <br />IF THERE IS. A.'WES" ANSWER. TO, ANY. PART. OF QUESTION OR 3, AN ADDITIONAL.: <br />QUESTIONNAIRE (AVAILABLE FROM HR OR LEGAL) MUST BE FILLED OUT AND <br />SUBMITTED WITH Tff CONTRACT, <br />Service Provider Name: Reid Middleton, Inc... <br />Si nature: <br />Printed Name <br />Phillip T. AbenrothTitle Survey Manager <br />(Retirement Form Approved by City Attorney's Office June 15, 2014) <br />