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<br />Page 16 of 21 <br />ATTACHMENT "E" <br /> <br />RETIREMENT STATUS FORM (SIGNATURE REQUIRED)-COUNTY RETAINS THIS FORM <br /> <br />ALL CONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPLETE AND SIGN <br /> <br />SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br /> <br /> Did you retire from one of the State of Washington Retirement Systems? __ Yes __ No <br /> Did you retire before age 65 using the 2008 early retirement factors (ERF)? __ Yes __ No <br /> Will you be receiving direct compensation for these services? __ Yes __ No <br /> Will you be receiving indirect compensation for these services? __ Yes __ No <br /> <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Print):__________________________ <br /> <br />Signature:_____________________________ Last Four Digits of Social Security No.____________________ <br /> <br />Date:_____________________ <br /> <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br /> <br />1. Contractor has been a member of a Washington State Retirement System? __ Yes __ No <br /> If yes, which system and plan? <br /> <br /> __ Teacher’s Retirement System (TRS) __ Plan 1 __ Plan 2 __ Plan 3 <br /> __ School Employees’ Retirement System (SERS) __ Plan 2 __ Plan 3 <br /> __ Public Employees’ Retirement Systems (PERS) __ Plan 1 __ Plan 2 __ Plan 3 <br /> __ Public Safety Employees’ Retirement System (PSERS) __ Plan 2 <br /> __ Law Enforcement Officers’ & Fire Fighters’ Retirement System (LEOFF) __ Plan 1 __ Plan 2 <br /> __ Washington State Patrol Retirement System (WSPRS) __ Plan 1 __ Plan 2 <br /> __ Judicial Retirement System (JRS) <br /> <br />2. Is the Contractor a retiree of a Washington State Retirement System? __ Yes __ No <br />3. Did the Contractor retire before age 65 using the 2008 ERF? __ Yes __ No <br /> <br />I have verified the information above using MRV or by contacting DRS. <br /> <br />COUNTY REPRESENTATIVE (Please Print):______________________________ <br /> <br />Signature:____________________________ Date:_____________________