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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 No <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? _ Yes A 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 />CONTRACTOR (Full name of contractor as in DRS filings -Please Print):ure�o1 rip/ Q0101 <br />Signature: z Last Four Digits of Social Security No. 6 / 1 <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 _Plan <br />Is the Contractor a <br />2 _Plan <br />Retirement <br />3 <br />_ School Employees' Retirement System (SERS) _ <br />Plan <br />2 _ <br />Plan <br />3 <br />_ Public Employees' Retirement Systems (PERS) _ Plan 1 _ <br />Plan <br />2 _ <br />Plan <br />3 <br />_ Public Safety Employees' Retirement System (PSERS) _ <br />Plan <br />2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System <br />(LEOFF) <br />_ Plan 1 _ Plan 2 <br />_ Washington State Patrol Retirement System (WSPRS) _ <br />Plan <br />1 _ <br />Plan <br />2 <br />_ Judicial Retirement System (JRS) <br />2. <br />Is the Contractor a <br />retiree of a Washington State <br />Retirement <br />System? <br />_Yes <br />_ No <br />3. <br />Did the Contractor <br />retire before age 65 using the <br />2008 ERF? <br />_Yes <br />_ No <br />I have verified the information above using MRV or by contacting DRS. <br />COUNTY REPRESENTATIVE (Please Pri <br />Sign <br />Date: <br />COUNTY RETAINS THIS FORM <br />Page 17 of 21 <br />