Signed and Dated Response to This Request for PERA Information and a W-9 Form

Please Note: Payments for services will not be processed until we have received your

signed and dated response to this request for PERA information and a W-9 form.

January 20, 2016

Effective July 1, 2005, the Colorado Revised Statute § 24-51-1101(2), requires employers under the Colorado Public Employees’ Retirement Association (PERA) to make employer contributions on all payments for services, such as salary, stipend or consultant payments, made to PERA retirees. Please help us collect the required information by checking the appropriate box below, signing this form, and mailing or faxing this form back to the address listed to the left of this paragraph. NOTE: If you are currently contributing to PERA but are not retired, please mark the “NO” box and indicate at the bottom of this form that you are contributing to PERA but are not retired. If you are unsure on how to complete the following yes or no statements, please contact PERA at 303 832-9550 for guidance.

Yes, I am a current PERA retiree or working through/for an affiliated party who is a PERA retiree as defined in C.R.S. § 24-51-1101(2). An affiliated party includes, but not limited to, your relative by marriage, by blood or adoption and a person or entity whom you have some sort of shared beneficial financial agreement with. PERA retirees who work as independent contractors using an APS Agreement for Contracted Services form are required to complete a Disclosure of Compensation form and submit it to PERA and to Aurora Public Schools. A copy of that form can be obtained on PERA’s website www.copera.org, or by calling 303-832-9550. Effective January 1, 2011, earnings of PERA retirees working as independent contractors will be subject to the 8 percent working retiree contribution. The working retiree contribution will be deducted by PERA from the retiree’s monthly benefit.

No, I am not a PERA retiree or working through an affiliated party, as explained above, who is a PERA retiree as defined in C.R.S. § 24-51-1101(2). By marking “no” and signing this form, I (the Contractor/Consultant) represent and warrant: (i) that the Contractor/Consultant is not a retiree from the Aurora Public Schools nor from any other employer covered by PERA as defined in C.R.S. § 24-51-1101(2); and (ii) if the contractor/consultant is an entity of any kind, that it is not owned nor operated by any PERA retiree or affiliated party of the PERA retiree (such as, but not limited to, a spouse or relative), as provided in C.R.S § 24-51-1101(2). The Contractor/Consultant shall indemnify and hold the Aurora Public Schools harmless from any breach of the foregoing representations and warranty and for claims made by PERA that arise out of or are related to the Contractor/Consultant’s performance of any services as or by a PERA retiree.

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Contractor/Consultant Signature Retiree or Affiliated Party Social Security #

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Printed or Typed Name of Contractor/ Retiree or Affiliated Party Name

Consultant

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Date Phone Number

If you have any questions, please call me at (303) 365-5810, ext. 28924.

Sincerely,

Tom McNish

Accountant

Aurora Public Schools

Revised 01-20-16