2012/05/23 Council Agenda Packet

Ii STATE RETIREMENT SYSTEMS FORM ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM 1. Does Service Provider have twenty-five (25) or more employees? ® Yes ❑ No _ IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW. • IF NO: ANSWER QUESTIONS 2 AND 3. 2. If a Service Provider employee will perform Work under this Professional Services Agreement, did that employee retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes n No 3. Answer the appropriate question below for Service Provider's business organization: Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System(SERS), or Teachers' Retirement System (TRS)? ❑ Yes n No Partnership. If a partner will perform Work under this Professional Services Agreement, did that partner retire under the Public Employers' Retirement System • (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? n Yes ❑ No Limited Liability Company. If a member will perform Work under this Professional Services Agreement, did that member retire under the Public Employers' Retirement System (PERS),School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? I I Yes I I No Corporation. If a shareholder will perform Work under this Professional Services Agreement, did that shareholder retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement • System (TRS)? Yes ❑ No • Service Provider Name: \c 30�Q�` ` C D5 , � Service Provider Phone Number: �Lk 1-S1- � v\ % Signature: @,,1 caeN Printed Name: (ky(*Title: (Retirement Form Approved by City Attorney's Office January 1,2010) 72