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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES A <br /> ALL SERVICE PROVIDERS MUST COMPLETE ANDGREEMENT <br /> SIGN THIS FORM <br /> I. Does Service Provider have twee <br /> IF YES: SKIP -five 25 or more em to ees? g Yes ❑ No <br /> QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW. <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> 2. If a Service Provider em to ee will perform Work under this Professional Services Agreement, <br /> did that e11p lovee retire under the Public Employers' Retirement System (PERS), School <br /> g <br /> Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes g 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❑ No <br /> Partnership. If a artner 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 (TRS)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 (TRS)or Law <br /> Enforcement Officers and Fire Fighters plan (LEOFF)? ❑ Yes 0 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 g 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: r-tcC Q-ows:.t j 0.c i5c6\ �P_ � ��c cs��A-U <br /> Sin e: Printed Nam • r c • . �Q i vtc <br /> g 8.74 ( 1•rtle ` �Qu-� <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />