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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? ❑ Yes E 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 < 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)? [1 Yes n No <br /> Partnership. If a partner will perform Work under this Professional Services Agreement, <br /> did that partner retire under the Public Employers' Retirement System(PERS), School <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)? n Yes ❑ No <br /> Service Provider Name: Jac Kare h Coii 5LA 1 b n6� L.L,C <br /> Service Provider Phone Number: 4z 5 - 96 5 -z z E3 <br /> Signature: � � ,�� Printed Name:jack,S Title: (9 wner <br /> c� <br /> (Retirement Form Approved by City Attorney's Office January 1,2010) <br /> 36 <br />