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' 9 <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? [ 1' es ❑ 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' 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 ❑ 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 /> 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 ❑ No <br /> Service Provider Name: &IRA � i 'e . <br /> Service Provide• 'hone Ni ber: 42,s- - /az - 76 Z( <br /> Signature: ', <br /> gn __ Jar., Printed Name: V:11). `045 <br /> (Form Approved by City Attorney's Office January 1,2010) <br /> 272 <br />