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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 ["No <br /> IF YES: SKIP QUESTION2, 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 [ 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 [igt.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)? ❑ Yes INo <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 rogl 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)? ❑''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 /> Service Provider Name: DV VI (a-0 <br /> 614 04 Title: bl,3�✓/�, 2„�--�� <br /> Signa Printed Nam (� <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />