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3. <br /> 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(PERS),School <br /> Employees'Retirement System(SERS),Teachers'Retirement System(IRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes 4 No <br /> 3. Answer the appropriate question below for Service Provider's business orgrni7ation: <br /> Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System <br /> (PERS), School Employees'Retirement System(SERS), Teachers'Retirement System(IRS), <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Ye] 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 ❑ 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),Teachers'Retirement System(TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ 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 ❑ No <br /> IF <br /> 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'I'HH:CONTRACT. <br /> I. <br /> Service Provider ame• <br /> '5h ,/b1 <br /> 111 <br /> Sitrnature: / G i11 <br /> Ay� <br /> b i PrintedNameO[P �� t � "Title: /b` i/0 61. rumt0 <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br /> 162 <br />