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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 /> • <br /> Does Service Provider have twenty-five(25)or more employees? 0 Yes ❑ No �' <br /> �{- <br /> 5kYt IF YES: SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BELOW ` <br /> IF NO ANSWERQ UESTIONS 2 AND 3 �, � 'fR 1* 4.1,M ',c 4�-. � 2 dJ: .+. tr4 a � � '� �i�y t��r - 'as✓ " �� � <br /> yytt <br /> i t <br /> 42. If a Service Provider employee will perform Work under this Professional Services Agreement, <br /> iMiic did that employee retire under the Public Employers' Retirement System(PERS),School <br /> 4` Employees' Retirement System(SERS),Teachers' Retirement System(TRS),or Law <br /> '� 'Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes ❑ No <br /> -3. Answer the appropriate question below for Service Provider's business organization: ,• <br /> 4} Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System <br /> 2y <br /> (PERS),School Employees'Retirement System(SERS),Teachers' Retirement System(TRS), <br /> f_l�c <br /> l }f Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes❑ No k y a c <br /> ,.A: 'Partnership. If a partner will perform Work under this Professional Services Agreement,did <br /> ,,3:i..45,4;that partner retire under the Public Employers' Retirement System(PERS),School Employees' <br /> : Kif'Retirement System(SERS),Teachers' Retirement System(TRS)or Law Enforcement Officers <br /> x <br /> and Fire Fi hters lan(L,EOFF) ❑ Yes [� <br /> 1; f t<z,4rFXth --ilv l a ` kiitti°o1f 01.4.00-::'i- <br /> (146,f, <br /> 4 ,.f Limited Liability Company. If a member will perform Work under this Professional Services <br /> fr `;Agreement,did that member retire under the Public Employers' Retirement System(PERS), <br /> ..441#4,4-School Employees' Retirement System(SERS),Teachers' Retirement System(TRS)or Law <br /> 14r: Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No• > <br /> t f .4 ,�'E#Tai $c-t,ax t4 �? ,, . *;"FtO <br /> >l Corporation. If a shareholder will perform Work nder 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 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 /> G' <br /> Service Provider Name: k'� S <br /> .„, <br /> Signature: 404_ 'rinted Name;T"K" itle: <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />