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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? <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 i_ No <br />_Yes :t No <br />_Yes ~ No <br />_Yes j: No <br />CON JOR (Full name of contractor as in DRS filings-Please Print): VA"'< EL-, N (C_,~L-- <br />Date: 1/-z q/t 4 ---+, ---,,~-~-- <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? <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 17 of 21