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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 0 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(TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 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 System(TRS), <br /> Law Enforcement Officers and Fire Fighters.plan(LEOFF)? ❑Yes❑ 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 Workunder 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 :E]_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 /> Service Provider Name: //i+ Cro S t% <br /> /14 <br /> - N �'Signature: � . ��,;0� Printed Name: rt-t- 4ud�cd. <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />