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ATIACHMENT "E" <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 <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />No <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Print): ___________ _ <br />Signature : _____________ Last Four Digits of Social Security No . ________ _ <br />Date : _________ _ <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below1 <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) Plan 1 <br />_ School Employees' Retirement System (SERS) <br />_ Public Employees' Retirement Systems (PERS) 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 />Signatu re: ____________ _ Date : ________ _ <br />Yes <br />Yes <br />No <br />No <br />Page 16 of 21