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I <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? ® Yes ❑ 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 Agreement, <br />did that employ retire under the Public Employers' Retirement System (PERS), School <br />Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? ❑ Yes X 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 System <br />(PERS), School Employees' Retirement System (SERS), Teachers' Retirement System (TRS), <br />Law Enforcement Officers and Fire Fighters plan (LEOFF)? ❑ Yes ❑ No <br />Partnership. If a partner will perform Work under this Professional Services Agreement, did <br />that partner retire under the Public Employers' Retirement System (PERS), School Employees' <br />Retirement System (SERS), Teachers' Retirement System (TRS) or Law Enforcement Officers <br />and Fire Fighters plan (LEOFF)? ❑ Yes ❑ rTo <br />Limited Liability Company. If a member will perform Work under this Professional Services <br />Agreement; did that member retire under the Public Employers' Retirement System (PERS), <br />School Employees' Retirement System (SERS), Teachers' Retirement System (TRS) or Law <br />Enforcement Officers and Fire Fighters plan (LEOFF)? ❑ Yes ❑ No <br />Corporation. If a shareholder will perform Work under this Professional Services Agreement, <br />did that shareholder retire under the Public Employers' Retirement System (PERS), School <br />Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br />Enforcement Officers and Fire Figliters plan (LEOFF)? ❑ Yes 11 No <br />IF THERE IS A "YES" ANSWER TO ANY PART OF QUESTIONS 2 OR 3, AN ADDITIONAL <br />QUESTIONNAIRE (AVAILABLE FROM HR OR LEGAL) MUST BE FILLED OUT AND <br />SUBMITTED WITH THE CONTRACT. <br />Service Provider Name: t -t -2- I�(E)(='' ; ►,�` <br />Si ature: Printed Name: Ps)•-.� E l Title: V1 U <br />c-rl-n r__ rroved by City At cniey s Offc�- fun?c I i 201 .) <br />29 <br />