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Page 16 of 17 ATTACHMENT "E" RETIREMENT STATUS FORM (SIGNATURE REQUIRED)-COUNTY RETAINS THIS FORM ALL CONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUST COMPLETE AND SIGN SECTION 1: CONTRACTOR COMPLETES THIS SECTION: Did you retire from one of the State of Washington Retirement Systems? ___ Yes ___ No Did you retire before age 65 using the 2008 early retirement factors (ERF)? ___ Yes ___ No Will you be receiving direct compensation for these services? ___ Yes ___ No Will you be receiving indirect compensation for these services? ___ Yes ___ No CONTRACTOR (Full name of contractor as in DRS filings – Please print: Bill Clarke Signature: _______________________________ Last Four Digits of Social Security No. _____ Date: __________________________ SECTION 2: COUNTY COMPLETES THIS SECTION: [Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] 1. Contractor has been a member of the Washington State Retirement System? ___ Yes ___ No If yes, which system and plan? ___ Teacher’s Retirement System (TRS) ___Plan 1 ___ Plan 2 ___ Plan 3 ___ School Employees’ Retirement System (SERS) ___ Plan 2 ___ Plan 3 ___ Public Employees' Retirement Systems (PERS) ___ Plan 1___ Plan 2 ___ Plan 3 ___ Public Safety Employees’ Retirement System (PSERS) Plan 2 ___ ___ Law Enforcement Officers’ & Firefighters’ Retirement System (LEOFF) Plan 2 ___ Plan 3 ___ ___ Washington State Patrol Retirement System (WSPRS) ___ Plan 1 ___ Plan 2 ___ ___ Judicial Retirement System (JRS) 2. Is the Contractor a retiree of a Washington State Retirement System? ___ Yes ___ No 3. Did the Contractor retire before age 65 using the 2008 ERF? ___ Yes ___ No I have verified the information above using MRV or by contacting DRS. COUNTY REPRESENTATIVE (Please Print): _ Signature: _______________________________ Date: ________________ COUNTY RETAINS THIS FORM