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• <br /> • <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 ZNo <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 /> Employed' 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 /> Sole Proprietor. Did Service Provider retire under the Public Employers' Retirement System <br /> (PERS). School Employees' Retirement System(SES),Teachers' Retirement System (TRS), <br /> Law Enforcement Officers and Fire Fighters plan (LEOFF)? ❑ YesZ No <br /> Partnership. If a partner will perform Work under this Professional Services Agreement. did <br /> that partner recite 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 <br /> • <br /> Limited Liability Commnv. If a member will perform Work under this Professional Service' <br /> Agreement. did that member retire under the Public Employers' Retirement System (PERS). <br /> • <br /> School Employees' Retirement System (SERS),Teachers' Retirement System (TRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes ❑ No <br /> clo_T)ration. 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 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 /> Sen ice Provider Name: l ezy t `'r I�^ -Pt/1VLt-A`" <br /> Si;nature% X-- Printed Name:41e n 14414tIckTitle: l 'l?,v _-- <br /> (Retirement Form Approved by Cite Attorney's Office June 15.20141 <br />