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ATTACHMENT tiE" <br />RETIREMENT STATUS FORM (SIGNATURE REQUIRED)-COUNTY RETAINS THIS FORM <br />ALL CONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPLETE AND SIGN <br />SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />Did you retire from one of the State of Washington Retirement Systems? <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? <br />Will you be receiving direct compensation for these services? <br />Will you be receiving indirect compensation for these services? <br />_Yes ..J. No <br />Yes J No <br />.../ Yes No <br />Yes -.:INo <br />CONTRACTOR (Fuli name of contractor as in DRS filings-Please Print): K)'v~). fo1",,...('" I c .... I'k-O /~G <br />Signature: ?~ Last Four Digits of Social Security No._L--_3 _2-_0 _____ _ <br />,/ <br />Date: 10-7 -If" <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />{Use Member Reporting Verific:ation (MRV) to verify the past retirement membership and doc:ument below] <br />1. Contractor has been a member of a Washington State Retirement System? <br />If yes, which system and plan? <br />_ Teacher's Retirement System (TRS) <br />_ School Employees' Retirement System (SERS) <br />_ Public Employees' Retirement Systems (PERS) <br />Plan 1 <br />Plan 1 <br />_ Public Safety Employees' Retirement System (PSERS) <br />Plan 2 <br />Plan 2 <br />Plan 2 <br />Plan 2 <br />Yes <br />Plan 3 <br />Plan 3 <br />Plan 3 <br />No <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 />2. Is the Contractor a retiree of a Washington State Retirement System? <br />3. Did the Contractor retire before age 65 using the 2008 ERF? <br />I have verified the information above using MRV or by contacting DRS. <br />COUNTY REPRESENTATIVE (Please Print):, ___________ _ <br />Signature: ____________ _ Date:. __________ _ <br />COUNTY RETAINS THIS FORM <br />Yes <br />Yes <br />No <br />No <br />Page 15 of 19