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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 be receiving direct compensation fo r these servi ces? Will you be receiving indirect compensation for these services? _Yes )i_ No Yes X No Yes X No Yes X No CONTRACTOR (Full name of contractor as in DRS filings -Please Print):~C~\o_r.j_(K'~~e'--~--+-a:-~_~'S~_ Signature: ~!lilctu~ Last Four Digits of Social Security No. __ t-/_~_q ____ _ 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? If yes, which system and plan? _ Teacher's Retirement System (TRS) _ School Employees' Retirement System (SERS) _ Public Employees' Retirement Systems {PERS) Plan 1 Plan 1 _ Public Safety Employees' Retirement System (PSERS) Plan 2 Plan 2 Plan 2 Plan 2 Yes Plan 3 Plan 3 Plan 3 No _ 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