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STATE RETIREMENT SYSTEMS FORM ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM 1. Does Service Provider have twenty-five(25)or more employees? ❑ Yes No IF YES: SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BEL W. iI IF NO: ANSWER QUESTIONS 2 AND 3. I 2. If a Service Provider employee will perform Work under this Professional Services Agreement, did that employee retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS),Teachers' Retirement System(TRS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes g No i 3. Answer the appropriate question below for Service Provider's business organization: Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System (PERS),School Employees' Retirement System(SERS),Teachers' Retirement System(TRS), Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes El No Partnership. If a partner will perform Work under this Professional Services Agreement,did 1 that partner retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS),Teachers' Retirement System(TRS)or Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No Limited Liability Company. If a member will perform Work under this Professional Services Agreement,did that member retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS),Teachers' Retirement System(TRS)or Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No Corporation. If a shareholder will perform Work under this Professional Services Agreement, did that shareholder retire under the Public Employers' Retirement System(PERS), School Employees' Retirement System(SERS),Teachers' Retirement System (TRS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes No IF THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL QUESTIONNAIRE(AVAILABLE FROM HR OR LEGAL)MUST BE FILLED OUT AND SUBMITTED WITH THE CONTRACT. Service Provider Name: w✓M • Signature: inted Name NA l>.41441k: M " 7 L0111 (Retirement Form Approved by City Attorney's Office June 15,2014)