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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 /> • <br /> 1, Does Service Provider have twenty-five(25)or.more.employees? ❑ 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 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),o';iLaw. <br /> . Enforcement Officers and Fire Fighters plan(LEOFF)? ❑Yes ® No. <br /> 3. Answer the appropriate question below for Service Provider's business organ ..iition: <br /> Sole Proprietor. Did Service Provider retire under the Public Employers' Re.'cement System <br /> (PERS), School Employees' Retirement System(SERS),Teachers' Retirena.° rt System (TRS), <br /> Law Enforcement Officers and Fire Fighters plan(LEOFF)? ❑ Yes❑ N..i . <br /> • 1 <br /> Partnership. If a partner will perform Work under this Professional ServiceAgreement, 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 ❑ 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)? [1 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 n 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 HE CONTRACT. <br /> Serviee Pro•'4 er Name ) Ni 0)�(7-•--120Z Oôci4ij <br /> Skim •. _ „Ns Printed Name :CAS t1� Q Title: 1%`"� Q� <br /> (Retirement Form Approved by City Attorney's Office June 15,2014) <br />