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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PERSONAL SERVICES CONTRACT <br /> THE HEARING EXAMINER PRO TEM MUST COMPLETE AND SIGN THIS FORM <br /> 1. Does the wring Examiner Pro Tern have twenty-five (25) or more employees? ❑ <br /> Yes 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 Hearing Examiner Pro Tern employee will perform services under this Contract, did <br /> that employ retire under the Public Employers' Retirement System (PERS), School <br /> Employe Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ <br /> Yes No <br /> 3. Answer the appropriate question below for the Hearing Examiner Pro Tern's business <br /> organization: <br /> Sole Proprietor. Did the Hearing Examiner Pro Tem retire under the Public Employers' <br /> Retirement System(PERS), School Employees' Retire t System (SERS), or <br /> Teachers' Retirement System (TRS)? ❑ Yes o <br /> Partnership. If a partner will perform services under this Contract, did that partner retire <br /> under the Public Employers' Retirement System (PERS), School Employees' <br /> Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ Yes <br /> No <br /> Limited Liability Company. If a member will perform services under this Contract, did <br /> that member retire under the Public Employers' Retirement System (PERS), School <br /> Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ <br /> Yes [ 10 <br /> Corporation. If a shareholder will perform services under this Contract, did that <br /> shareholder retire under the Public Employers' Retirement System (PERS), School <br /> Employees' Retirement System (SERS), or Teachers' Retirement System (TRS)? ❑ <br /> Yes I kl<To <br /> Hearing Examiner Pro Tern Name: V1C 4C .A \V <br /> Hearing Examiner Pr•..Tern :Phone Numbe 2 S-5 'D*7 2 <br /> Si:nature:c Printed Name: c�'l�Title: <br /> Hearing Examiner Pro Tem Contract 2018 6 <br />