Laserfiche WebLink
STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> 1. Does Service Provider have twenty-five(25)or more employees? Yes $. <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BEL 6�'%. <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> 2. If a Service Provider em i loyee will perform Work under this Professional Services <br /> Agreement,did that employee retire under the Public Employers'Retirement System <br /> (PERS),School Employees'Retirement System(SERS),Teachers'Retirement tem <br /> (TRS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? Yes 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 <br /> System (PERS),School Employees'Retirement System(SERS),Teachers'Retireme <br /> System(TRS),Law Enforcement Officers and Fire Fighters plan(LEOFF)? Yes <br /> Partnership. If a partner will perform Work under this Professional Services Agreement, <br /> did that partner retire under the Public Employers'Retirement System(PERS), School <br /> Employees'Retirement System(SERS),Teachers'Retirement S -m(TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? Yes No <br /> Limited Liability Company. If a member will perform Work under this Professional <br /> Services Agreement,did that member retire under the Public Employers'Retirement <br /> System (PERS), School Employees'Retirement System(SERS),Teachers'Retirement <br /> System (TRS)or Law Enforcement Officers and Fire Fighters plan(LEOFF)? Yes <br /> Corporation. If a shareholder will perform Work under this Professional Services <br /> Agreement,did that shareholder retire under the Public Employers'Retirement System <br /> (PERS), School Employees'Retirement System(SERS),Teachers'Retirement Syt <br /> (TRS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? Yes No <br /> IF THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN <br /> ADDITIONAL QUESTIONNAIRE(AVAILABLE FROM HR OR LEGAL)MUST BE <br /> FILLED OUT AND SUBMITTED WITH THE CONTRACT. <br /> Service Provider Name:Reede1✓ t AJ & <br /> Signatu Clly Printed Name:' Title- <br /> (Retirement Form Approved by City Attorney's Office June 15, 2014) <br />