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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PERSONAL SERVICES CONTRACT <br /> THE HEARING EXAMINER MUST COMPLETE AND SIGN THIS FORM <br /> 1. Does the Hearing Examiner have twenty-five (25) or more employees? ❑ Yes [KNo <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3,AND SIGN BELOW. <br /> IF NO: ANSWER QUESTIONS 2 AND 3. <br /> 2. If a Hearing Examiner employee will perform services under this Contract, did that <br /> employee retire under the Public Employers' Retirement System(PERS), School <br /> Employees' Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ <br /> Yes \No <br /> 3. Answer the appropriate question below for the Hearing Examiner's business <br /> organization: <br /> Sole Proprietor. Did the Hearing Examiner retire under the Public Employers' <br /> Retirement System(PERS), School Employees' Retirement System(SERS),or <br /> Teachers' Retirement System(TRS)? ❑ Yes ❑ No <br /> Partnership. If a partner will perform services under this Contract, did that partner retire <br /> under the Public Employers' Retirement System(PERS), School Employees' <br /> Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ Yes ❑ <br /> No <br /> Limited Liability Company. If a member will perform services under this Contract, did <br /> that member retire under the Public Employers' Retirement System(PERS), School <br /> Employees' Retirement System(SERS),or Teachers' Retirement System(TRS)? ❑ <br /> Yes g No <br /> Corporation. If a shareholder will perform services under this Contract, did that <br /> shareholder retire under the Public Employers' Retirement System(PERS), School <br /> Employees' Retirement System(SERS), or Teachers' Retirement System(TRS)? ❑ <br /> Yes ❑ No ���� __ ��__ <br /> Hearing Examiner Name: Ste►-2.v .— � <br /> Hearing Examiner Phone Number: -fib ?S�( p 3� <br /> Signature:ca 9 !ILEA , ,le Printed Name: le: AA Ct <br /> Hearing Examiner Contract 2017 <br />