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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> • <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGN THIS FORM <br /> 1, Does Service Provider have twenty-five(25) or more employees? ❑ Yes Z 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)? ❑Yes Ei 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)? E Yes ❑X 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 r: 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 /> Employees' Retirement System (SERS),Teachers'Retirement System (TRS); or Law <br /> . Enforcement Officers and Fire Fighters plan(LEOFF)? n 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: , 4AV.lr" • 'ha-(-2 - Yev—t 4.. --1 `lt vi 1 .1441 <br /> Signat("7 <br /> . V `&-(4.. .. Printed Name1i S& , tiii� le: tilc c 1 <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />