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ATTACHMENT "E" RETIREMENT STATUS FORM (SIGNATURE REQUIRED}-COUNTY RETAINS THIS FORM ALL CONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPLETE AND SIGN SECTION 1: CONTRACTOR COMPLETES THIS SECTION: Did you retire from one of the State of Washington Retirement Systems? Did you retire before age 65 using the 2008 early retirement factors (ERF)? Will you b e re ceivin g direct comp e nsation for the se se rv ices ? Will you be receiving indirect compensation for these services? _Yes 't-No _Yes X, No _Yes X No _Yes 't No CONTRACTOR (Full name of contractor as in DRS filings-Please Print): G y-eca>~J " I P. John sfo)'"\ Signature: Last Four Digits of Social Security No. _ _.6 .... 'f_.__9,__2.. ____ _ Date : __ JCl~\i\~, ~?~q_1 _20~/ j_ SECTION 1 : COUNTY COMPLETES THIS SECTION: [Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] 1. Contractor has been a member of a Washington State Retirement System? Yes No If yes, which system and plan? _ Teacher's Retirement System (TRS) Plan 1 Plan 2 Plan 3 _ School Employees' Retirement System (SERS) Plan 2 Plan 3 _ Public Employees' Retirement Systems (PERS) Plan 1 Plan 2 Plan 3 _ Public Safety Employees' Retirement System (PSERS) Plan 2 _ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) _ Plan 1 _ Plan 2 _ Washington State Patrol Retirement System (WSPRS) Plan 1 Plan 2 _ Judicial Retirement System (JRS) 2. Is the Contractor a retiree of a Washington State Retirement System? 3. Did the Contractor retire before age 65 using the 2008 ERF? I have verified the information above using MRV or by contacting DRS . COUNTY REPRESENTATIVE (Please Print): ____________ _ Signature: ____________ _ Date: --------- COUNTY RETAINS THIS FORM Yes Yes No No Page 17 of 21