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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? 0 Yes X 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),or Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes X 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(PERS), <br /> School Employees' Retirement System(SERS),Teachers' Retirement System(TRS),Law <br /> Enforcement Officers and Fire Fighters plan(LEOFF)? 0 Yes 0 No <br /> Partnership. If a vartner will perform Work under this Professional Services Agreement,did that partner <br /> retire under the Public Employers' Retirement System(PERS), School Employees' Retirement <br /> System(SERS),Teachers' Retirement System(TRS)or Law Enforcement Officers and Fire <br /> Fighters plan(LEOFF)? 0 Yes 0 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)? 0 Yes 0 No <br /> Corporation. If a shareholder will perform Work under this Professional Services Agreement,did that <br /> shareholder 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 X 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 Pro 'der N e:Sharing Wheels Community Bike Shop <br /> Signature: -- - -, Name: 12.: n vn-pY)Title: 0�ro ) re'S °Y-4, <br /> Page 15 <br /> (Form Approved by City Attorney's Office January 7, 2010, updated November 21, 2016) <br />