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3 <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? k Yes ❑ No <br /> IF YES: SKIP QUESTION 2,SKIP QUESTION 3,AND SIG B LOW. <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 eniplovee 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 /> 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 0 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 /> Employees' Retirement System(SERS),or Teachers' Retirement System(TRS)?• <br /> ❑ Yes ❑ No <br /> • <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 ❑ .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 : 0.No <br /> Service Provider Name: //at' d, /717 rizics,661 iXoty, / • <br /> Service Provi•e Phone'NU nber: -S Xo7/ O 0-- . <br /> Signature: �' ,�:`// Printed Name: ) /,# .,I% Title: o E <br /> r — <br /> (Form Approved by City Attorney's Office January 1,2010) <br /> 41 <br />