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6 <br /> • <br /> - STATE RETIREMENT SYSTEMS FORM <br /> • ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE`AND SIGN THIS FORM <br /> • s' •-" t :-ra --6c :-.,:c # v'w .r v`�i*v h+ @$ h•.: + .-9.— r:,r>;<y V';.` #'{ 4; <br /> h4 ,y,� � r '.•x. 4 xt s' ��-,�.'rt`iS.•.....�,.��9• J d,r.9 ir`"�pe <br /> - � ''▪ ./..;.•.W:,;;,....:;.,: _ c.h e y r {� v� �` i�p;�}Fi•'�^ � .�, �;yr'.,�:.'•�'A4He�� ?-y'�;."r:^'.eine^ ",o s r. 'fie <br /> .. ••' , � 's,'k k wr 1.,ya_ -h5 ::Falx4 k r t,Mi. 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',4�ems: ,.41. v `'`� r ... ;•.:',.?' #'N i r-.• v�,'.'v .``� -4#` <br /> Solg Propri toi '-',,3 d Service Pr.Or er.retire' er'the ' b is ployef�sz=Ret en, g. <br /> •c."�; h,4,;:;, ,Jnr• ' ' xs. v �i S ✓ ! _ ,.y i - 4 - r S ^ •:::..1;.:7- -;•-•-.,,,,,:.,. <br /> { -J;_ . <br /> • ,.$ystem'r"ERS Sc ool Emuil yees'Rpetirement'System(SFR , ehers' <br /> . .,t*.u, �•• �� �K'!! t �•i..v c�5�k5 ,ryh alt <br /> Retirement 'ste �'fRS)? Q 'es ❑ No 1',,t ?� <br /> • ' s_/tom,�. .-,',;•,'::::,-;-::! <br /> t r✓A: • '4 2.a. c�. '�.fi xy� ,..-,4%4.1...:. .,...,.:,,..,,7.-0,1•.; xs'L• k: <br /> Partnership . f a partner Wh11 per€orm work utlaer is 'rofessione .. ✓, _ <br /> c �''."`;r: w �• re` •v ri gcA : e^ r'L) t 1 � 1..... .`•x••�. ., '": .a 3-tcr `.. ��'7 <br /> �'.�' s r .,Lc t.w r. 'ibJ�� ,E. --:-..,*.-,-A-..3-. .,xr• - <br /> t, ; ')kgreemen,� d that partner eeire;.timer_;�h,e rubhe Employerseufemen�t`.7 e a <br /> APES)'• e bel.•Em lAyees Reti ment System(SERS), Qr.( eachers:..ettre e� w <br /> y''.:..•:--g-,-:„,.-.,:•,-.,-.;.:,-...7.-..-.!--,,,„ N.6.-.7.,:.,....!':-.?-4v , ' t a, „j; 7ro w ✓r � xE z fyv .,$x x ,' <br /> r n-System )?. f{,"q,�k No-r:,',7:.,83:,. <br /> ' °•A? �! .`F�; ,5 ▪ . ,$,-• to rr i* G f. <br /> r,{ ':• 'L-nt'9 h.it 7r r ....... <br /> .:: z,✓.;R C3 'ift 4 ! " ° Yr:f - ;Y,.•.-4..7.:,'.';�� .dc r'=' a+ <br /> '+.cjOi ,y,�"!'--',"`T,.,i:y ?`H �f .f �^G `4 .y • x`% y �Yr'i E l - .f 1 <br /> f k a �. ,•o'r 4 „e e{.. ris• Y h Ab � �a .o. „.a. '1,44::/..,.04.-;!;;,5,: <br /> h' ,. .11 ed Liability Comp •y: . 'member .� 1 orM, o, k under lus 4.gesto,, <br /> t L.,k-v:r- •sc'r t4i.lia .:"..B . �. a1 £ �` 3.✓Y•.,.. P'+d"' {, - ray; �.„, S ' a•cr * b . <br /> -..,:,:Services:Agreexnent — t mem' be re 1 et tn1 er-the Ili ltc'Emplb eIs ke ement <br /> i.. rt Vireo > a a $ ate , Mid' a w,?`� v.�i%.1., 9:-..l r{ � <br /> o System(P �), c'hop`1 Empl e y s -'e 1 embnt pyste.m��S)�or•TeaherS <br /> •;!:::-•$,•14,..,-..,.....-_,..,....,k;,„....,...-:-.,,,,-.:,Y : T« far.: g 3�.• , .. m,„.,,,,,„,..,au i r + "�,it ar,S,f 3 �` <br /> •' ' ;a, tirement rc-ystem(TIvS r• es ] FV u'�`'' `;�' s , r x i <br /> •, '# J,.+.* .p,Rw; p'4 YC ,im.. y leN •.{5x11, �'d r tfi' M q' r1i v r:'tc ',. ▪ J 1 S*;�J ` ✓ <br /> h ✓ �x S.A ,i 3 ^ ', .. 4111' .T+ 04�'. 4P ' 1C <br /> r #y �a° rr' �,u�;�3.,,, ay �' b �,�7� ?^^,�.x;C.� �� 1 fc +f ▪� � �� '�r°`'� � . <br /> rc}- r 1 `•°:A,2 'r" i ' +Ks,.,�41 .r �1 s * ✓ 3 xx*i . ::c .w , •p3*, x•'n,r ✓ <br /> ,V { Co oratioli'{I .�:sharehtil er� orm W.or1 nder this_Pro�et'sibl► 1 -r•• ce' <br /> v V;u � • �' x m+4h-?'�5., 2•� 6'�t�et s• y off `�""��{xj;3• xG,•�t.".5�3�.'f so tri c, � '�' <br /> `�'�at regimen 'd d't�t:s"�arr`e ib�der retire under• 'e�P: ehc Em i1oyers a gime : y to n <br /> `,fir rr ii:,.• ..:1,F.' .:( . ,: ' ¢- 0. ✓ t'r ' iw7 4 ,,, ,�tx ° cam. to r su <br /> ' ''. ). oo1'4111P eutement • 6 br Teaeh� k ehr nt�A> <br /> o.r c '§', d* c - o s .. ,�1155-+ ✓E•x c r 'fib ^r <br /> hd M ['t {L .�tCtA� � � 5 d� ✓ ,, s +C 9d f t , sc ion: <br /> a tia .ss� !: S Stem S L ei' 0 S.4.,Lw o '` r '.i.�. ?-111/*�,. !d,x^rx , G�i C i- d t 4 rs t <br /> ay 'r 4 i <br /> , <br /> ✓ � <br /> Service ProlIz e..arae V& � '.1.114,....i.., - 5., y" f � ; ��-$1,WIt� .. , <br /> ek ft <br /> :SeceProm rrnone nb�r 1, . : ,-ai � �35-, 4:.,i s .fI. 4 ,. <br /> 1x � + p : 3rAfas 5 "'� g: tY h '' . o � <br /> • yy: • ' F ..V£' : { yt tau.r e•� ....P..•`,'•- 1. ,.r C i' p �$� r, %rc' ' t .' + t } ' 'Sigh ure Y � 'acd N : st �_t C <br /> 1 1 <br /> (State Retirement Form Approved by City Attorney's Office January 1,2010) <br /> 94 <br />