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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 Provider have twen -five 25 or more em to ees? ❑ Yes ( No <br />IF YES: SKIP QUESTION 2, SKIP QUESTION 3, AND SIGN <br />IF NO: ANSWER QUESTIONS 2 AND 3. <br />2. If a Service Provider employee 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), or Teachers' Retirement <br />System (TRS)? ❑ Yes [4 No <br />3. Answer the appropriate question below for Service Provider's business organization: <br />Sole Pro rietor. Did Service Provider retire under the Public Employers' Retirement <br />System (PERS), School Employees' Retirement System (SERS), or Teachers' <br />Retirement System (TRS)? ❑ Yes ❑ No <br />partnership. If a partner will perform Work under this Professional Services Agreement, <br />did that rtner retire under the Public Employers' Retirement System (PERS), School <br />pa <br />Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? <br />❑ 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), or Teachers' <br />Retirement System (TRS)? ❑ Yes ❑ No <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), or Teachers' Retirement <br />System (TRS)? ❑ Yes 0 No <br />Service Provider Name: yietf 10- �wp, <br />lv1c.. <br />Service Provider Phone Number: <br />Si <br />Printed Name•' LUw,,-R k Title: <br />(Form Approved by City Attorney's Office January 1, 2010) <br />247 <br />