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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 Providerhive twenty-five(25)or more:employees? lif £k"es, . . No <br /> IF,YES.`SKIP QUESTION2; SKIP QUESTION 3,AND,:SIGN'BEL)W. <br /> IF NO; ANSWER QtSTIONS 2 AND 3. ' , <br /> 2: If a Service.P;rbyider employee will per-kern Work under this Professionals Services Agreement, <br /> did that emp1oyee?retire under the.Pub'lic E3np1oyers'Retirement System,(PERS),School <br /> Employees'Retirement System(SERS)?Teachers' Retirement)System(TRS) or Law <br /> ° ,,Enforcement Officer&and Fire Fighters plan",(LEOFF)%' 0 Yes 01 NO. <br /> .. .. a s .. <br /> Answer the pptopriat&question below for Service Pr tier' s business organization , <br /> Sole:Proprietor Did Service Provider retire under the'Pi b 'c Emplojyers'Retirement System, <br /> (PERS), School Employees Retirement Sys em�•(SERS),_,Teachers Retirement System (TRS!, <br /> Law Enforcement Officers andFire Fighters plan(LEOFF)?: D Yes Li No <br /> Partnership. If apartner wilt perform Wok under tlhs�Professional Services Agreemen•1,did <br /> b , <br /> that partner retire undFr the Public Employers Retirement System(PERS); School Employees <br /> Retirement System(P.ERS),Teachers'Retirement System(TRS)or I,aw Enforcement kers <br /> and Faire Fighters piAn(LEOFF ? LI Yes 0 No - , , <br /> Limited Liability dompany If a Member will'I erform Work under this Professional;Services <br /> Agreement,did that member retire under•the fPpblic Employers' Retirements System(PERS),. <br /> School Ennployees,•Retirement System( ERS),Teachers Rett em.ent System-(TkS)or Law <br /> Enforcement Officers and Fire Fighters P n(LEOFF)? D Yes [] No"' , <br /> ° Corporation:. If a shareholder will perform Arbrk under this Professional ServiieesAgreement, <br /> did shareholder retire under the Pub"li,c; <br /> = o � Emtployers-.Retirement System(PERiiSchool <br /> Employees' Refiremerit`S`stem SERS °Teachers' Retirement System T -= or Law <br /> ° Enforcement Officers and Fire Fighters plan 1 LEOFF)? E. Yes Q No <br /> 1 IF THERE IS A"yE-S"ANSWER TO AN.*f RT OF QUESTIONS 2 0R3,_Ali ADDITIONAL <br /> 'QUESTIONUIRE(AVAILABLE FROM AROR LEGAL)MIDST BE FOALID OUT AND' <br /> SUBMITTER WITH THE CONTRACT ` ,,' <br /> Service Provider Name kt 1 ! �"1L'V. .` . : <br /> Signature ° : i.t ,11 <br /> Pra *ted Name: _ Title: <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />