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` r , <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 Ei No <br /> IF YES SKIPQUESTION 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 employee 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)? 0 Yes E 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 E 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)? 0 Yes ® No <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 Fighters plan(LEOFF)? ❑ Yes E No <br /> IF TH FRE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE FROM BR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITH IlIE CONTRACT. <br /> Service Provider Name: fel C • 5.--vol/- <br /> / <br /> r olt <br /> Signature: -owA Printed Name: gait $7 'I itle: ?' vcip'd/io/ <br /> Page 9 <br />