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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFF.SSIO\:kL SERVICES ES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> 1. Does Service Provider have twenty-live(25)or more employees? ❑ Yes ® 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 ®' No <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> Sole Proprietor. I)id 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)? ❑ Yes ® 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 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 (IRS),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 e: W1:412,D0 1rAt8Aiz <br /> Signature: Printed Name:' 4 rLb 113Aa title:t MEER/aft LATO <br /> (Retirement form .Approved h Attorney.`Office June I;. 20 I-1) <br />