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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PERSONAL SERVICES CONTRACT <br /> HEARING EXAMINER MUST COMPLETE AND SIGN THIS FORM <br /> 1. Does the Hearing Examiner have twenty-five(25) or more employees? ❑ Yes rKNo <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(SERB);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(IRS)? n <br /> Yes 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: S--0.9-0V- <br /> Hearing <br /> L--Hearing Examiner Phone Number: jcj 2.4v- ®?cts <br /> 0- AID <br /> r_fC ) <br /> Signature: ���, �,/1I Printed Name: c�i°( le: { til <br /> Hearing Examiner Contract 2017 6 <br /> 7 <br />