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ATTACHMENT "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? _ Yes _x- 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 X No <br />Will you be receiving indirect compensation for these services? _ Yes X No <br />CONTRACTOR (Full name of contractor as in DRS filings -Please Print): SAFEbuilt Washington, LLC <br />Signature: Last Four Digits of Social Security No. TIN#81-0927666 <br />Date: June 13, 2018 <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br />1. Contractor has been a member of a Washington State Retirement System? _ Yes _ No <br />If yes, which system and plan? <br />Teacher's Retirement System (TRS) —Plan 1 <br />_ Plan 2 _ <br />Plan 3 <br />_ School Employees' Retirement System (SERS) <br />_ Plan 2 _ <br />Plan 3 <br />_ Public Employees' Retirement Systems (PERS) _,_,_ Plan 1 <br />` Plan 2 r <br />Plan 3 <br />_ Public Safety Employees' Retirement System (PSERS) <br />_ Plan 2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) <br />Plan 1 <br />_ Washington State Patrol Retirement System (WSPRS) <br />_ Plan 1 _ <br />Plan 2 <br />— Judicial Retirement System (JRS) <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 />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 />Plan 2 <br />Page 16 of 20 <br />