Laserfiche WebLink
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 />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 GFANo <br />3. Answer the appropriate question below for Sei vice 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 aap rtner 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 (TRS)? ❑ 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 lzj-No <br />Coloration. 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 (SERB), or Teachers' Retirement <br />System (TRS)? ❑ Yes ❑ No <br />Service Provider Name: 1`( „tel ks5 ��►s'_`�'� <br />Service Provider Phone Number: <br />lure: <br />Piim' ed i"Iame: <br />S C'�ICF�L' -�E10, <br />1;� <br />Title: <br />