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17 <br /> STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> e twee -five 025 employees? [�Yes D No <br /> 1. Does Service Provider hav tY )or more P <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW, <br /> IF NO: ANSWER.QUESTIONS 2 ANIS 3. <br /> 2. If a Service Provider employee will perform Work wider this Professional Services <br /> Agreement;did that employee retire under the Public Employers'Retirement System <br /> (PERS),School Employees' R remerit System(SERS),or Teachers' Retirement <br /> System(TRS)?. ❑ Yes I 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' Retireinent <br /> System(PERS),School Employees' Retirement System(SER$),of Teachers' <br /> Retirement System(TRS)? ❑ Yes D No <br /> Partnership. If a partner will perform Work under this Professional Services Agreement, <br /> did that partner retire under the Public Employers' Retirement System(PERS),School <br /> Erimployees' Retirement System(SERS),or Teachers' Retirement System(TRS)? <br /> ❑. Yes ❑ No <br /> Limited Liability.Company. If a member will perform Work under this Professional <br /> Services Agreement,did that member retire tinder the Public Employers'Retirement <br /> System:(PERS)•,School Employees' Retirement System(SERS),or Teachers' <br /> Retirement System(TRS)? 0 Yes ❑ 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' eti.renient System(SERS),or Teachers' Retirement <br /> System(TRS)? ❑ Yes No <br /> - Service Provider Name: A4'- <br /> Service Provider Phone Number: 20,e,— 2 8 /—O Gib <br /> Signature: ----7-t--. P 3 Printed Name:�h o m i s M Z i k itle: Pre S,A c n-r <br /> (Forte Approved by City Attorney's Office January i,2010) <br /> 157 <br />