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ATTACHMENT ''E'' <br />RETTREMENT STATUS FORM (STGNATURE REQUTRED)-COUNTY RETATNS THtS FORM <br />ALt CONTRACTORS, SERVICES CONTRACTORS, AND TNDEPENDENT CONTRACTORS MUST COMPLETE AND StGN <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 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 />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 />COU NTY REPRESENTATIVE (Please Print) <br />Date <br />Yes <br />Yes <br />@*o <br />&*o <br />fi)v"t\J <br />Yes rn\\-/ <br />No <br />No <br />CONTRACTOR (Fu ll name of ntra or as in DRS filings-Please Print):Bill Clarke <br />Signature Last Four Digits of Social Security No.3831 <br />.T LJ <br />1. Contractor has been a member of a Washington State Retirement System? <br />lf yes, which system and plan? <br />Yes <br />Date: <br />SECTION 2: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document belowl <br />No <br />_ Teacher's Retirement System (TRS) _ Plan 1 _ 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 _ Plan2 <br />_ Washington State Patrol Retirement System (WSPRS) _ Plan L _ Plan 2 <br />_ Judicial Retirement System (JRS) <br />Yes <br />Yes <br />No <br />No <br />Signature <br />COUNTY RETAINS THIS FORM <br />Page 15 of 18