2010/06/16 Council Agenda Packet

1.4 STATE RETIREMENT SYSTEMS FORM ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM 1. Does Service Provider have twenty-five (25) or more employees? ® Yes ❑ No IF YES: SKIP QUESTION 2, SKIP QUESTION 3, AND SIGN BELOW. IF NO: ANSWER QUESTIONS 2 AND 3. 2. If a Service Provider employ will perform Work under this Professional Services Agreement, did that em llooyee retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes ❑ No 3. Answer the appropriate question below for Service Provider's business organization: Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes ❑ No Partnership. If a partner will perform Work under this Professional Services Agreement, did thatap rtner retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes ❑ No Limited Liability Company. If a member will perform Work under this Professional Services Agreement, did that member retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes ❑ No Corporation. If a shareholder will perform Work under this Professional Services Agreement, did that shareholder retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes ❑ No Service Provider Name:�v �Ln� �'„�,c� C Service Provider Phone Number: SignaturAc��j 21-7 4�tL Printed NametU1 7'ytc-A�q, Title: Vic: -Y,0 (Retirement Form Approved by City Attorney's Officel aPary 1, 20 10)