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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.Does Service Provider have twenty-five (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 (TRS),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.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)?☐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 (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 ☐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:___Webprism______________________________ <br />Signature:___Printed Name:_Ashley Santamaria_Title:Owner______________ <br />(Retirement Form Approved by City Attorney’s Office June 15,2014)