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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 /> I Does Service Provider have twenty-five(25)or more employees? ❑ Yes 4,No 1 <br /> IF YES: S -Qt1LESTfiaN 1, &.t .;? f ..E .. i,2k,AN_" S..472s.: .(., it". <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(TRS), or Law <br /> Enforcement Officers and Fire Fighters nlan(LEOFF)? ni Yes 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/ -m(TRS), <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes❑ No lq 1 <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)? 0 Yes ❑ No A A <br /> I.0 mi-,,d tiphiiity( my. Ifs.member will mrfortrt Work order 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)? 0 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 /> Errioye s' se e" Syne/(S..54.S)., s 'e's 4e'lf,TSy mem i s KS); - _ ToN <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes ❑ No' i /19- <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 /> 51 <br /> / <br /> Sit attire: Alit I% ,grater/ .d Name: 'v Title O <br /> , w <br /> R0s3 <br /> (Ret�,renerra Form Approved by ay Araoroey's Office Jerre 15,2 4) <br />