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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHIVIENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AN)SIGN THIS FORM• <br /> 1. Does'Service Provider have'twenty f ve-(25)of more employees? Q Yes14 No <br /> IF YHS:SKIP QUESTION.2,SKIP QUESTION 3,AND.SIGN BELOW.. <br /> IF NO;ANSWER QUESTIONS 2 AND 3. . <br /> • <br /> 2. 'Ifs 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)? fl Yee 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 0 No . <br /> Partnership..If a partner will perform Work under flus Professional Services Agreement,. did <br /> that parter 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)? D 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),Tee. Chars'Retirement System(TRS)or Law <br /> Enforcement Officers and Fire_Fighters pian(LEOFF)? ❑ Yes ❑ No Ii <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.(GFAFF)? Q Yes i.No <br /> IF THERE ISA"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> QDESTIONNAIRE(AVAILABLE FROM BR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITH THE CONTRACT. ., /� <br /> Service Provider Name:Dttl 1 N IQ i Acr,Ol-) 2050 U r c E e edu r <br /> Si: atu Printed Name:Min i oiJl41 Title: a EC l7 ieee are <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />