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ATTACHMENT ''E'' <br />RETIREMENT STATUS FORM (STGNATURE REQUTRED)-COUNTV RETATNS THtS FORM <br />AIL CONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPLETE 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 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 name r as in DRS filings-Please Print):Bill Clarke <br />Signature Last Four Digits of Social Security No 3831 <br />.T L3 <br />Yes <br />Yes <br />@*o <br />&^o <br />@t"r -No <br />No <br />Date <br />SECTION 2: COUNTY COMPLETES THIS SECTION: <br />IUse Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br />L. Contractor has been a member of a Washington State Retirement System? _ Yes _ No <br />lf yes, which system and plan? <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 L _ 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 L _ 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 />Signature: Date <br />Yes <br />Yes <br />No <br />No <br />COUNTY RETAINS THIS FORM <br />Page 15 of 18