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ATTACH NT ''E" <br />RETTREMENT STATUS FORM (STGNATURE REQUTRED)-COUNTY RETAINS THIS FORM <br />ALL CONTRACTORS, SERVTCES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPTETE AND SIGN <br />sEcTlON 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 />CoNTRACTOR (Full of ntractor as in DRS filings-Please Print): <br />Signature:Last Four Digits of Social Security No. <br />Yes .k'No <br />Yes -ti 'No <br />;Y'ves - No <br />- Yes }1t{o <br />lr^-*./ <br />Date:r'?t,/t4eL.''7 .': <br />,?c./---,-/ / <br />'/SECTION 2: 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 />- <br />Yes <br />- <br />No <br />lf yes, which system and plan? <br />_ Teacher's Retirement System (TRS) <br />- <br />Plan L <br />- <br />Plan 2 <br />- <br />Plan 3 <br />_ School Employees' Retirement System (SERS) _ Plan 2 _ Plan 3 <br />_ Public Employees' Retirement Systems (PERS) _ Plan 1- _ Plan 2 _ Plan 3 <br />_ Public Safety Employees' Retirement System (PSERS) _ Plan 2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) _ Plan l- _ Plan 2 <br />_ Washington State Patrol Retirement System (WSPRS) _ Plan 1- _ Plan 2 <br />_ Judicial Retirement System (JRS) <br />2. ls 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 />Date: <br />Yes <br />Yes <br />No <br />No <br />Signature <br />COUNTY RETAINS THIS FORM <br />Page 16 of 18