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13 <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 [t//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' etirement System(SERS), or Teachers' Retirement <br /> System(TRS)? 0 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' Retir went System(SERS),or Teachers' <br /> Retirement System(TRS)? 0 Yes g 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)? ❑ Yes [t� 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 [�I 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' etirement System(SERS), or Teachers' Retirement <br /> System(TRS)? ❑ es [4 No • <br /> Service Provider Name. G'' Livi i'l J Tv 14- <br /> Service Provider Phone ber: if_ . ) t', <br /> 5. <br /> Si na -re L1 tit LA 1 Y Printed N. . , hII1 <br /> g [f. T d itle:/fl rp_xo— )9— <br /> (Foran Approved by City Attorney's Office January 1,2010) <br /> 109 <br />