Kate Livingston 12/6/2017 - Laserfiche WebLink

STATE RETIREMENT SYSTEMS FORM ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM 1. Does Service Provider have twenty-five (25) or more employees? ❑ Yes Ej "No IF YES: SKIP QUESTION 2, SKIP QUESTION 3, AND SIGN BELOW. IF NO: ANSWER QUESTIONS 2 AND 3. 2. If a Service Provider employee will perform Work under this Professional Services Agreement, did that employee retire under the Public Employers' Retirement System (PERS), School Employees' etirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes [l No 3. Answer the appropriate question below for Service Provider's business organization: Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System (PERS), School Employees' Retir ment System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes [✓ No Partnership. If a partner will perform Work under this Professional Services Agreement, did that partner retire under the Public Employers' Retirement System (PERS), School Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes QrNo Limited Liability Company. If a member will perform Work under this Professional Services Agreement, did that member retire under the Public Employers' Retirement System (PERS), School Employees' Retir ment System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes [ No Corporation. If a shareholder will perform Work under this Professional Services Agreement, did that shareholder retire under the Public Employers' Retirement System (PERS), School Employees' letirement System(SERS), or Teachers' Retirement System (TRS)? C Yes M No Service Provider Name: 2-111 114 C1670/‘,1 Service Provid- Phone N er: �Z - 17-f3 . eof Signature: 'X12 Printed Name: Title: 0 t rg- (Retirement Form Approved by City Attorney's Office January 1,2010)