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I <br /> 1 <br /> • 1 <br /> 1 <br /> STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT i <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM s <br /> i <br /> 1. Does Service Provider have twenty-five(25)or more employees? Pc Yes [ No <br /> IF YES: SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BELOW. 1 <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> s <br /> 1 <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)? ❑Yes [ No <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> • <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(I,ROFF)? f[Yes fl 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)? ❑ Yes U No <br /> Limited Liability Company. If a member will perform Work under this Professional Services <br /> Agreement,did that member retire under the Publie Employers'Retirement System(PERS), . <br /> School Employees'Retirement System(SERS),Teachers'Retirement System(TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? fl 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 C No <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 Pru •e ame: DLR Group <br /> 1111 <br /> Signature:,li Printed Name: Lori Coppenrath Title: Principal <br /> )11 <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br /> 90 <br />