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5 , <br /> per' 13 <br /> STATE RETIREMENT SYSTFIV FORM <br /> ATTACHMENT TO PR .t+, SSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN TIlTS FORM <br /> I. Does Service Provider have twenty-five(25)or more employees? n Yes to <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SION BELOW. <br /> IF NO:ANSWER QUESTIONS 2 AND 3, <br /> 2. If a Service Provider to ee will'performWork 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)? ❑ Yes % No <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> • <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)?' ❑ Yes 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)? n Yes rAt.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(IRS)? ❑ 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' Retirement System(SERS), or Teachers'Retirement <br /> System(TRS)? ❑ Yes <br /> 110,/ <br /> �vNo • <br /> Service Provider Name: t Vi <br /> 44) <br /> Service Provide_ one Num D er: <br /> Sig:nat 'anted 1an�e: 4Title: J \T.IleAv <br /> .__ <br /> Form Approved by City Attorney's Office January 1,2010) <br /> • <br /> 69 • <br />