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RETTREMENT STATUS FORM (STGNATURE REQUTRED) <br />COUNTY RETA'A'S THIS FORM <br />SECTION 2: COUNW COMPLETES THIS SECTION (Use Member Reporting <br />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 />[] vEs n rvo <br />lf yes, which system and plan? <br />tr Teacher's Retirement System (TRS): <br />I ptan't f]ptan z I plan g <br />I School Employees' Retirement System (SERS): <br />I Plan 2 D Plan 3 <br />tr Public Employees' Retirement Systems (PERS): <br />flPtant IPlanz IPlang <br />n Public Safety Employees' Retirement System {PSERS): <br />I ptan z <br />I Law Enforcement Officers'& Fire Fighters'Retirement System (LEOFF): <br />nptanl I Ptanz <br />n Washington State Patrol Retirement System (WSPRS): <br />f]Ptant n Plan2 <br />n Judicial Retirement System (JRS) <br />2. ls the Contractor a retiree of a Washington State Retirement System?flvrs lruo <br />3. Did the Contractor retire before age 65 using the 2008 ERF?lvgs lruo <br />I have verified the information above using MRV or by contacting DRS. <br />COUNTY REPRESENTATIVE (Please Print) <br />Signature Date: <br />Professional Services Agreement <br />Page 19 <br />GOUNTY RETAINS THIS FORM