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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 No <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 ERS), School <br /> Employees' Retirement System(SERS),Teachers' Retirement System RS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes o <br /> 3. Answer the appropriate question below for Service Provider's business organization: <br /> Sole Proprietor. Did Service Provider retire under the Public Employers' Ret' ment System <br /> (PERS), School Employees' Retirement System(SERS),Teachers' Retire nt System(TRS), <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes o <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 /> O <br /> and Fire Fighters plan(LEOFF)? ❑ Yes '1Vo <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 S tem(TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes Kro <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(T ),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes o <br /> IF MERE 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:[t-CLJzs� `/ 117 u^\ <br /> /14j1/4-1 q-APAI <br /> Signature: 61ti• t"'nted Name: Title: Ct: '✓• <br /> ---4(24/2-A-1 '765% Ldql <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />