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STATE RETIREMENT SYSTEMS FORM <br /> A'I"FA('IIMI N'F 1'O PROFESSIONAL,SERVICES AGREEMENT <br /> Al,1,SERVICE PROVIDERS M11S'I'COMPLETE AND SIGN THIS NORM <br /> I. Does Service Provider have twenty-five(25)or more employees? ❑ Yes RS No <br /> IF YES:SKIP QUESTION 2,SKIP QUESTION 3,AND SIGN BELOW. <br /> IF NO:ANSWER QUESTIONS 2 AND 3. <br /> 2. II'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,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)? 0 Yes ❑ 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 ❑ 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:4y/fld0 0,'i�i+.7/4If <br /> Ari,2 <br /> Signature' �� . Printed Name:1.9401607,"/' Title: eff419.I <br /> (Retirement Form Approved by City Attorney's 01)1cc June IS,2014) <br />