Laserfiche WebLink
STATE RETIREMENT 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 No <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELO . <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 Syst m(TRS),or Law <br /> Enforcement Officers and Fire Fighters pla'h(LEOFF)? El Yes 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)? El Yes El 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(TRS)or Law Enforcement Officers <br /> and Fire Fighters plan(LEOFF)? El Yes El 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)? El 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 Sy to (TRS), or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? El No <br /> IF THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE FROM RR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITH THE CONTRACT. /� /� /� <br /> Service Provider Name: CV)ef►le-lY;CS I,AQe)tid N ltscac;11, /4C. <br /> Signature: ____Ai------- <br /> ___Ai -t Printed Name: C I St-,Arid: Title: Qfp,,c -t /Ch,, <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />