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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 /> 1. E)oes Service Provider have twenty-five(25)or more employees? ❑ Yes 04 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 (IRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes Did 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 (IRS). <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes rg 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 (IRS)or Law Enforcement Officers <br /> and Fire Fighters plan(LEOFF)? ❑ Yes ❑ 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 /> 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 HR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WiTH THE CONTRACT. <br /> Service Provider Name: -J Cc4Gf 54r) Ptah i <br /> pWN -10e60 <br /> npWErLC — <br /> Sif nature: / Printed ame: f4c p ( `title: <br /> (Retirement Form :approved by City Attorney's Office June I ,2014) <br />