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STAT]RETWnICNT 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? Yes J1 No <br />IF YES: SK1TP 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 and Fire Fighters plan (LEOFF)? 1 Yes L 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)? E] Yes No <br />Partnership. If a partner will perfonn 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)? ` Yes fl No <br />Limited Liability Company. If a mernber will perform Work under this Professional Services <br />Agreement, did that piember retire under the Public Employers' Retirement System (PERS), <br />School Employees' Retirement System (SERS), Teachers' hers' Retirement System (IRS) 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 THERE IS A "YES" ANSWER TO ANY PART OF QUESTIONS 2 OR 3, AN ADDITIONAL <br />QUESTIONNAIRE (AVAILABLE FROM BR OR LEGAL) MUST BE ¥JLLED OUT AND <br />SUBMITTED wtrn THE CONTRACT. <br />Service Provider Name: David Evans and Associates, Inc. <br />Ur it71::C/OLu <br />O'J C-u], :-r s'i trJt n.00Iv4 <br />Signature: Gil Laas � ��°: �� hi- � Printed Gilbert J. Laas 'Title: Project Surveyor, Sr. Associate <br />e�C .:1n V :rl 1tr Pz inted Name: Clme: <br />(Retirement Form Approved by City Attorney's Office June 15, 2014) <br />