Laserfiche WebLink
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? ® 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 <br /> • <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 /> • <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(IRS)? ❑ 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: HM UV/L, <br /> Service Provider Phone Number: (42S)450 - (P 20O ' <br /> act <br /> Printed Name:Wht B/ tle. ', U� I► %Je 11Signature: `� <br /> 0 <br /> (State Retirement Form Approved by City Attorney's Office January 1,2010) <br /> 33 <br />