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• <br /> J <br /> STATE RETIREMENT SYSTEMS FORM <br /> ATTACH M:ENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COIVIPLE'tE AND SIGN THIS FORM <br /> • <br /> • <br /> • <br /> 1. Does-Service Provider have twenty-five(25)Or more employees? ❑0 Yes WC, No <br /> IF YES: SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BELOW. <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> • <br /> 2. If a Service Provider employee will perfotrri Work under this Professional Services Agreement, <br /> did that employee retire under the Public Employers'Retirement System(PERS),School <br /> Einployees''R.etirement System(SERS),Teachers'Retirement System(TRS),.or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes 14 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-perfai r.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 andFire Fighters plan(ELOP.07 0 Yes.00 Nd <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 ,X1 No <br /> IF'TRE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL • <br /> QUESTIONNAIRE(AVAILABLE FROM BR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITITILLE CONTRACT. <br /> Service Provider Name: s t'.1 i cv 5: 1M_. . . <br /> �!. r f, Printed Name: €,'! 4 ;C.. wapTitle: 9 .� <br /> Signature: p, <br /> (Retirement Form.Approved by City Attorney's Office J6:0 15,2014) <br />