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4 <br />STATE RETIREMENT SYSTEMS <br />ALL SERVICE PROVIDERS MUST COMPLETE THIS PAGE <br />Provider Name: <br />Provider Phone Number: 42-5--212-,900 3: <br />1. Does Service Provider have twenty-five (25) or more employees? YE <br />IF YES: SKIP REMAINDER OF PAGE <br />IF NO: ANSWER QUESTIONS 2 AND 3 <br />2. If a Service.Provider employee will perform Work under this Professional Services Agreement, did that employee <br />retire under the Public Employers' Retirement System (PERS), School Employees'. Retirement System (SERS), or <br />Teachers' Retirement System (TRS), at Law Enforcement Officers and Fire Fighters plan (LEOFF)? <br />3. Answer ONLY the question below appropriate: for Service Provider's business entity: <br />Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System (PERS), School <br />Employees! Retirement System (SERS), or Teachers'Retirement System (TRS), or Law Enforcement Officers and <br />Fire Fighters plan (LEOFF)? <br />Partnership. If a partner will perform Wank -under this Professional Services Agreement, did that partnerretire <br />under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or <br />Teachers' Retirement System (TRS), or Law Enforcement Officers and Fire Fighters plan (LEOFF)? <br />Limited Liability Company. If a member will perform Work under this Professional Services Agreement, did that <br />member retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System <br />(SERS), or Teachers' Retirement System (TRS), or Law Enforcement'Officers and Fire Fighters plan (LEOFF)? <br />Corporation. If a shareholder will perform -Work under this Professional Services Agreement, did that shareholder <br />� <br />retire under thel'ublic. Employers' -Retire System (PERS), School Emplo-, enLSysteni (S. E.RS), or-. <br />Teachers' RdiYe-nient SYStem (TIRS); or Lava Friforceniell-L Officers Lnd Fire Fighters plats (LEOFF)? <br />UL <br />-)2.11 P V <br />E,, <br />