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ATTACHMENT'D" <br />RETTREMENT STATUS FORM (S|GNATURE REQUTRED) <br />COUNTY REIA'ruS THIS FORM <br />ALL CONTRACTORS, SERVICES CONTRAGTORS, AND INDEPENDENT <br />CONTRACTORS MUST COMPLETE AND SIGN <br />SECTION 1: GONTRACTOR COMPLETES TH|S SECTTON <br />1. Did you retire from one of the State of Washington Retirement Systems? <br />n yrs ,F*o2. Did you retire before age 65 using the 2008 early retirement factors (ERF)? <br />nves F*o3. will you be receiving direct compensation for these services? <br />FYES [ ruo <br />4. will you be receiving indirect compensation for these services?I vrs F*o <br />coNTRAcroR (Full name of contractor as in DRS filings-please print): <br />Signature <br />Last Four Digits of Social Security Number;th/ <br />Date <br />Professional Services Agreement <br />Page 18