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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'? Z Yes 0 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)? 0 Yes .0 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)? 0 Yes 0 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)? d Yes 0 No. <br /> Limited Liability Company. If a member will perform Work under this Professional <br /> Services Agreement,did that member retireunder the Public Employers'Retirement <br /> System(PERS), School Employees'Retirement System(SERS), or Teachers' <br /> Retirement System(TRS)? 0 Yes 0 No <br /> Corporation. If a shareholder will perform Work under thisProfessional 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)? 0 Yes 0 No <br /> Service Provider Name: K0-14\ 1.t I I/ L? <br /> Service.Provider Phone Number: .� -VD-Ct.-wife . :X/yit <br /> Signature, 7 „r Printed Name:Law-re. Title: �rt rtic r 7o <br /> (State Retirement Form Approved by City Attorney's Office January I,2010) <br /> 42 <br />