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STATE RETIREMENT SYSTEMS <br /> ALL SERVICE PROVIDERS MUST COMPLETE THIS PAGE <br /> Service Provider Name: Barney&Worth,Inc. <br /> Servive Provider Phone Number: 503.222-0146 <br /> 1. Does Service Provider have twenty-five(25)or more employees? NO <br /> IF YES: SKIP REMAINDER OF PAGE <br /> IF NO: ANSWER QUESTIONS 2 AND 3 <br /> 2. If a Service Provider employee will perform Work under this Professional Services Agreement,did that employee <br /> retire under the Public Employers'Retirement System(PERS),School Employees'Retirement System(SERS),or <br /> Teachers'Retirement System(TRS),or Law Enforcement Officers and Fire Fighters plan(LEO Kb)? <br /> NO <br /> 3. Answer ONLY the question below appropriate for Service Provider's business entity: <br /> Sole Proprietor.Did Service Provider retire under the Public Employers'Retirement System(PERS),School <br /> Employees'Retirement System(SERS),or Teachers'Retirement System(TRS),or Law Enforcement Officers and <br /> Fire Fighters plan(LEOFF)? <br /> Partnership.If a partner will perform Work under this Professional Services Agreement,did that partneerretire <br /> under the Public Employers'Retirement System(PERS),School Employees'Retirement System(SERS),or <br /> Teachers'Retirement System( RS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? <br /> Limited Liability Company.If a member will perform Work under this Professional Services Agreement,did that <br /> member retire under the Public Employers'Retirement System(PERS),School Employees'Retirement System <br /> (SEES),or Teachers'Retirement System(TRS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? <br /> Corporation.If a shareholder will perform Work under this Professional Services Agreement,did that shareholder <br /> retire under the Public Employers'Retirement System(PERS),School Employees'Retirement System(SERS),or <br /> Teachers'Retirement System(TRS),or Law Enforcement Officers and Fire Fighters plan(LEOFF)? <br /> NO <br /> 122 <br /> Page4 of 4 <br />