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7 <br /> STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> Provider ave twee =fives or more employees?;;.[]': Yes,' .;No:: <br /> 1,:Does Service .. .:..:... . ... ... . tY ( ...). <br /> IF Y•ES:.SKIP;QUESTION 2, SKIP QUESTION 3, AND SIGN BELOW:. <br /> IF NO:•ANSWER QUESTIONS 2 AND 3 . <br /> 2. :If a Service rovider:employee•will perform\Vorkunder this Professional Services <br /> Agreement, did that employee refire under the Public Employers' Retirement:System <br /> ERS)• ,School:Eiciiiployees'.Betirement System(SERB);or Teachers' Retirement <br /> System(TRS)? d;.Yes:: /4•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), SchoolEm•ployees' Retirement System(SERB), or Teachers' <br /> Retirement System(TMS)? 0 Yes [] No <br /> • a • awl erformWorlk ufoalSiviceAgrPnaeem nt,.. <br /> • .. <br /> • <br /> did that partner retire under the Public Employers',.Retirement System(PERS), School :..: <br /> Employees'..:R_etirement�System(SEMS),or:Teachers' Retirement System(TRS) <br /> [� Yes [� No: <br /> Work under'this Professional', <br /> Limited Liability Company If a member will perform , , . : <br /> • <br /> SeiviceAgreement,did that member retire under.the Public Employers' Retirement <br /> System(PERS),School-Employees' Retirement System(SERB),or Teachers'. <br /> ' Retirement System(TRS) <br /> 0,„Yes: No <br /> • Corporation If a:shareholder,will perform°Work under this Professional Services • <br /> Agreement,did that shareholder retire under the P_ublic Employers'Retirement System <br /> PERS), School Employees' Retirement System:(SERB),or Teacher`s':Retirement . <br /> System(TRS)? Q Yes Q No ; <br /> 2S <br /> Service Provider.N. � cLt BOOP) LLc' `b$'i <br /> Service.ProvideAfif. o ne N bet �4:;• ') . .:.i. <br /> Si attire: Printed Name E Atf <br /> (Form Approved by City Attorney's Office January 1,2010) <br /> 45 <br />