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ATTACHMENT ''E'' <br />RETIREMENT STATUS FORM (STGNATURE REQUTREDI-COUNTy RETATNS THtS FORM <br />Att CONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPTETE AND SIGN <br />SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />Did you retire from one of the State of Washington Retirement Systems? <br />Did you retire before age 55 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 />1. Contractor has been a member of a Washington State Retirement System? <br />lf yes, which system and plan? <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 <br />/ <br />Yes <br />Yes <br />-?*" <br />u/No <br />NoL4es <br />Yes D *o <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Print) Philip M. Backlund <br />Signature Last Four Digits of Social Security No <br />1no=-LUL -Date b- <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV] to verify the past retirement membership and document belowl <br />ves (No <br />Teacher's Retirement System (TRS) _ Plan L _ Plan 2 _ 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 />-Yes <br />X ruo <br />- <br />Yes {, *o <br />I DateSignature: <br />_> <br />e Print) <br />COUNTY RETAINS IS FORM <br />Page 15 of 20