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<br />SERVICE PROVIDER: Please fill in the spaces and sign in the box appropriate for your <br />business entity. <br />Corporation <br />Limited <br />Liability <br />Company <br />Partnership <br />______________________________________ <br />By: __________________________________ <br />Date: _________________ <br />Typed/Printed Name of Signer: ____________________ <br />Signer’s Email Address:_____________________________ <br />Title of Signer: __________________________________ <br />Sole <br />Proprietorship Signature:___________________________________ <br />Typed/Printed Name of Signer: ____________________ <br />Signer’s Email Address: _____________________________ <br />STATE RETIREMENT SYSTEMS / MUST BE COMPLETED BY ALL SERVICE PROVIDERS <br />1. Does Service Provider have twenty-five (25) or more employees? Yes No <br />IF YES: THIS BOX IS COMPLETE. SKIP QUESTION 2. <br />IF NO: ANSWER QUESTION 2. <br />2. Did any of Service Provider’s Personnel who will work under this Professional Services <br />Agreement 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 />For question 2, “Service Provider Personnel” includes Service Provider employees and <br />owners (such as shareholders, partners or members). If the Service Provider is a sole <br />proprietor, then “Service Provider Personnel” refers to the sole proprietor. <br />Sandy Brodahl <br />06/30/2023