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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? 1' j Yes n No <br />IF YES: SKTP 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 thatemployee oY ee retire under the Public Employers' Retirement System (PERS), School <br />� <br />Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? 11 Yes E No <br />3. Answer the appropriate question below for Service Provider's business organization: <br />Sole Proprietor, laid Service Provider retire under the Public Employers' Retirement System <br />(PERS), School Employees' Retirement System (SERE), Teachers' Retirement System ('IRS), <br />Law Enforcement Officers and Fire Fighters plan (LEOFF)? Yes D No <br />Partnership, If will perform Work under tills professional Services Agreement, did <br />l a partner_ <br />that partner retire under the Public Employers' Retirement System (PERS), School Employees' <br />Retirement System (SERE), Teachers' Retirement System (TRS) or Law Enforcement Officers <br />and Fire Fighters plan (LEOFF)? D 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 CMS) or Law <br />Enforcement Officers and File Fighters plan (LEOFF)? L Yes El 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 />System (SERS),eeseacersEm to' Retirement Th' Retirement System (TRS), or Law <br />p Y_ <br />Enforcement Officers and Fire Fighters plan (LEOFF)? . Yes No <br />IF THERE IS A "YES" ANSWER TO ANY PART OF QUESTIONS 2 OR 3, AN ADDITIONAL <br />QUESTIONNAIRE (AVAILABLE FROM BR OR LEGAL) MUST BE FRIED OUT AND <br />SUBMITTED WITH THE C ONTRAC To <br />Service Provider Name: FLA L< t ? p'ae -rJ oH,117C 7 Lt-c. <br />Signature: <br />Printed Name: <br />TJA,svki <br />• <br />(Retirement Form Approved by City Attorney's Office June 15, 2014) <br />f\rloEi <br />Title: Apk -tra <br />� <br />