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STATE RETIREMENT SYSTEMS FORM <br /> ATTACHMENT TO PROFESSIONAL SERVICES AGREEMENT <br /> ALL SERVICE PROVIDERS MUST COMPLETE ANI) SIGN THIS FORM <br /> 1. Does Service Provider have twenty-five(25)or more employees? Yes ❑ No <br /> IF YES: SKIP QUESTION 2, SKIP QUESTION 3, AND SIGH BELOW. i <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 /> fi <br /> Employees' Retirement System (SERS), Teachers' Retirement System (TRS), or Law <br /> Enforcement Officers and Fire Fighters plan(ELOPE)'? ❑ Yes H No <br /> I <br /> 1 <br /> 3. Answer the appropriate question below for Service Provider's business organization: t <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 n 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 (IRS)or Law Enforcement Officers <br /> and Fire Fighters plan (LEOFF)? ❑ Yes ❑ No <br /> Limited Liability Company. If a member will perform Work tinder this Professional Services <br /> Agreement,did that member retire under the Public Employers' Retirement System(PERS), <br /> I iSchool 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 /> t'.` t:i' ' IS A"YES"ANSWER TO ANY PART OF QUESTIONS 2 OR 3,AN ADDITIONAL <br /> 6 0l ONNAIRE(AVAILABLE FROM HR OR LEGAL) MUST BE FILLED OUT AND <br /> •tIBMITTED WITH THE CONTRACT. <br /> TServtce Provider Name: 1,1,',..,/ar c., 6 A4: irouue�kewt,,Cc". <br /> • ; �, J ./ <br /> s <br /> f, ,, <br /> n , ice, <br /> ®� Printed Name: c,e c(( <br /> ^, Title: /2'4,4 <br /> I dr <br /> ( Ment Form Approved by City Attorney's Office June 15,2014) <br /> '4 <br /> x <br />