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9 <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 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 Syst (TRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes g 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'Retire ent System(TRS), <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yeso <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 Employee? l <br /> Retirement System(SERB),Teachers'Retire nt System(TRS)or Law Enforcement Officers <br /> and Fire Fighters plan(LEOFF)? 0.Yes No I <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 ystein(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'RetirementSyst m(PERS),School <br /> Employees'Retirement System(SERS),Teachers'Retirement Sys ('LRS),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes No <br /> IF THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> QUESTIONNAIRE(AVAILABLE irROM RR OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITH THE CONTRACT'. <br /> Service Provider Name: /6 W w o 4 <br /> Signature: Prmted Naine: /r' ra v1 Ivt Fitle: e .°v4 1 '' <br /> / <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br /> 79 <br />