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A <br /> 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 'No <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW. <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 41 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), or Teachers' <br /> Retirement System (TRS)? ❑ Yes ❑ No <br /> Partnership. If a partner will perform Work under this Professional Services <br /> Agreement, did that partner retire under the Public Employers' Retirement System <br /> (PERS), School Employees' Retirement System(SERS), or Teachers' Retirement <br /> System (TRS)? ❑ 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 ❑ No <br /> Service Provider Name: in 051-5L— 55 aCui LeA <br /> Service Provider Phone Number: a.a — 53--ob5 S� <br /> P, <br /> /111 <br /> SignatuM" it Printed Namer►)-f bST LTitle: UiczQre.5r1 <br /> (Form Approved by City Attorney's Office January 1,2010) <br /> 68 <br />