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STATE RETIREMENT SYSTEMS FORM <br />AT'IAC iL MENT C PROFESSION4 L SER :ICES AGI EEM N T <br />SERWCE PROVIDERS MUST CO LETE AND SIGN THIS FORM <br />1. Does. Service Provider have twenty-five (25) or more employees? Yes i� 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 5: 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)? I Yes , I 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 X 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)? 1 Yes I 1 No <br />Er4 T ERE iS A "YES" ANSWER TO ANY PARS` OF QUES IONS 2 OR 3, AN ADDMWNA -1 <br />QUESTIONNAIRE (AVAILABLE FROM I111 OR L ; ,GAL) MUS BE IVJ LLE OUT AND <br />SU NUTTED '1D WITH THE CONTRACT. <br />Service Provider Name: /32-i/2)6z& <br />Signature <br />6‘..9,2-1)//vertiP2 nut <br />Printed Name: it f /!� i ofkThiantie• f /t bgeLe <br />(Retirement Form Approved by City Attorney's Office June 15, 2014) <br />