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ATTACHMENT "E'' <br />RETIREMENT STATUS FORM (SIGNATURE REQUIRED).GOUNW RETAINS THIS FORM <br />ALLCONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUSTCOMPLETE ANDSIGN <br />SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />Did you retire from one of the State of Washington Retirement Systems? <br />- <br />Yes <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? <br />- <br />Yes <br />Will you be receiving direct compensation for these services? <br />- <br />Yes <br />Will you be receiving indirect compensation for these services? <br />-_ <br />Yes <br />CONTRACTOR (Full name of as in DRS filings - Please print: Bill Clarke <br />Signature:Last Four Digits of Social Security No i 83 I <br />Date: E ?\v\ <br />SECTION 2: GOUNTY COMPLETES THIS SEGTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br />y'ruo"X tto-Y ruo <br />Jr.ro <br />1. Contractor has been a member of the 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 (Please Print) <br />Date: <br />Yes No <br />_ Teacher's Retirement System (TRS) <br />-Plan <br />1 <br />-Plan? -_ School Employees' Retirement System (SERS) <br />-Plan2 -_ Public Employees'Retirement Systems (PERS) <br />- <br />Plan 1-Plan2 <br />-_ Public Safety Employees' Retirement System (PSERS) Plan 2 <br />-_ Law Enforcement Officers' & Firefighters' Retirement System (LEOFF) Plan2 <br />-_ Washington State Patrol Retirement System (WSPRS) <br />- <br />Plan I <br />-Plan <br />2 <br />-_ Judicial Retirement System (JRS) <br />Plan 3 <br />Plan 3 <br />Plan 3 <br />Plan 3 <br />Yes <br />Yes <br />No <br />No <br />Signature: <br />COUNTY RETAINS THIS FORM <br />Page 16 of17