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• <br /> '.) '? <br /> STATE RETIREMENTSYSTEMSFORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE AND SIGNTIilS FORM <br /> 1. Does Service Provider have twenty-five(25)or more employees? l4 Yes Li 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)? n Yes El 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(DOFF)? C Yes Li No <br /> Partnership. If a partner will per-fatal Work under this Professional Services Agreement,did <br /> that partner retire under the Public Employers'Retirement System(PERS),School Employees' <br /> Retirement System(SERBS),Teachers'Retirement System(TRS)or Law Enforcement Officers <br /> and Fire Fighters plan(LEOFh)? 0 Yes 0 No <br /> F <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(IRS)or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes 0 No <br /> Corporation. If a shareholder older 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 pian(LEOFF)? 1 ! Yes IN No <br /> IP THERE IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> QTJESTIONNAIRE(AVAILAB7,T,FROM BR.OR LEGAL)MUST BE FILLED OUT AND <br /> SUBMITTED WITH THE CONTRACT. <br /> Service Provider-Name: 122..l,.kitfl c <br /> ,- <br /> Signature: ' ,4raktix_. Printed Tame:t ar« ,g„d r.Title: )4. 12,m y <br /> ‘S.24,,,, <br /> (Retirement Form Approved by City Attorney's Ofdc$21e 15,2014) <br />