Laserfiche WebLink
5 <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)? U Yes n 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)? n Yes I I No <br /> Partnership. If a partner will perfoini 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)? n Yes n No <br /> Limited Liability Company. If a member will perfotm 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)? I I Yes n 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 [A No <br /> Service Provider Name: titgal 65 P iet £ o.e 2 file-.... <br /> Service Provider Phone Number: 4=44Z-—66.0,0 <br /> Signature: ,.c Printed Nam 4/0 01Title k 7 <br /> trfU <br /> (Form Approved by City Attorney's Office January 1,2010) <br /> 40 <br />