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3 <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? I Yes f 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',Retirexienf System`(SERS), or Teachers' Retirement <br /> System(TRS)? ❑ Yes [] No <br /> 3 Answer the appropriate question below for Service Provider':s business organization <br /> Sole Proprietor. DidrService Provider retire under the Public Employers' retirement <br /> System(PERS), School Employees' Retirement System(SERS),'or Teachers' <br /> Retirement System(TRS)? ;'0 Yes Q 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 /> (PRS), <br /> E 'School Employees' Retirement System(SERS), or Teachers' Retirement <br /> System(TRS)? [I Yes ❑ No <br /> Limited Liability Company. If a member will perform Work under this Professional <br /> Services Agreement,ydid that member retire under the Public Employers':Retirement <br /> Sy stem(PERS,), School Employees' Retirement System(SERB), or Teachers' <br /> .: o <br /> Retirement System(TRS) Q Yes [� N <br /> Corporation If a shareholder will.perforin Work under this'Pro fessional Services <br /> f'4 t <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)? D Yes El No <br /> Service Provider"Name: Mwl 1,1eG&'y, 1.-1( <br /> Service;Provide one Number: Ce 10900 ; <br /> Signature '• ,� Printed Name: nov. ,Title:\(i �,!pear. <br /> (State Retirement Form Approved by City Attorney's Office January 1,2010) <br /> 45 <br />