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r <br /> STATE RETIREMENT SYSTEMS FORM 1 <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> 4 <br /> I <br /> 1. Does Service Provider have twenty-five(25)or more employees? ElYes ( No I <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 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 El No <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> ISole Proprietor. Did Service Provider retire under the Public Employers'Retirement System <br /> (PERS),School Employees'Retirement System(SERS),Teachers' Retirement System(TRS), l <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes❑ No 0 <br /> i <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 I <br /> Iand Fire Fighters plan(LEOFF)? 0 Yes ❑ No <br /> Limited Liability Company. If a member will perform Work under this Professional Services i <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)? ElYes 111No E <br /> ilCorporation. 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 k <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes in No <br /> 1 <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: 1),)` .5.7 sc „0-do V t#1-tyr i3..,-c ras=K t' ZL a, <br /> i <br /> k... 1 <br /> Signature:,...„.y.-i) <br /> �`%._ 41. Printed Name: l- L,A.).) >v''i' 7Title: e L. f'-+PI 'S S'cr`-"I'L <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br /> 1 <br />