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STATE RETIREMENT SYSTEMS FORM <br />ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br />AIL SERVICE PROVTE).ERS MUST COMPUTE A. SIGN THIS FORM <br />1. Does Servide Provider. have -twenty-five (25) or more employees? 0 Ye S o <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 EmployersRetirement System (PERS), School <br />EMPloyleSk Retirement System (SERS), Teachers' Retirement System (TRS), orLaw <br />Enforcement Officers and Fire Fighters plan (LEOFF)? [1] Yes 171'No <br />3. Answer the appropriate question below for Service Provider's business organization: <br />Sold Proprietor. Did Service Provider retire under the Public Employers' Retirement System <br />(PERS), Sthool Employees' Retirement System (SERS), Teachers' Retirement System (TRS), <br />LaW Elifordeinent Officers and. Fire Fighters plan (LEOFF)? Yes LI 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 Lay Enforcement Officers <br />and Fire Fighters plan (LEOFF)? 0 Yes it 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 (PE-RS), <br />School Employees' Retirement System (SERS), Teachers' Retirement System (TRS) or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? fl Yes {1 No <br />Corporation. If a shareholder will perform Work under this Professional Services Agrdeinent, <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)? LI Yes [1 No <br />IV Tit ERE IS A "YES". ANSWER TO ANY PART OF QUESTIONS .2 OR 3, AN ADDITIONAL <br />QUKSTIOrtINAIRE (AVAILABLE FROM HR OR LEGAL) 1VIITST BE FILLED OUT AND <br />SUBMITTED WITH THE CONTRACT. <br />.er,.s.tice Provider Name: <br />Signature: <br />fi <br />ft& <br />Printed Name: <br />(13-0-14t.PAPit Eon Apovedbi City AttoruPy's Office June 13, -2014) <br />tie; <br />