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ATTACHMENT'E" <br />RETTREMENT STATUS FORM (STGNATURE REQUTRED)-COUNTY RETAINS THIS FORM <br />ALLCONTRACTORS, SERVICES CONTRAGTORS, AND INDEPENDENT CONTRACTORS MUSTCOMPLETE AND SIGN <br />SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />Did you retire from one of the State of Washington Retirement Systems? <br />- <br />Yes X ruo <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? <br />- <br />Yes Y ttto <br />Will you be receiving direct compensation for these services? <br />- <br />Yes { t'lo <br />Will you be receiving indirect compensation for these services? <br />- <br />Yes { ruo <br />CONTRACTOR (Full name of as in DRS filings - Please pri nt: Bill Clarke <br />Last Four Digits of social Security *".W1Signature <br />Date:1r <br />SECTION 2: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br />L <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 />I <br />-Pien <br />2 <br />-_ School Employees' Retirement System (SERS) <br />-Plan2 -_ Public Employees'Retirement Systems (PERS) <br />- <br />Plan 1-Plan2 <br />-_ Public Safety Employees' Retirement System (PSERS) Plan2 <br />-_ Law Enforcement Officers'& Firefighters' Retirement System (LEOFF) Plan2 <br />-_ Washington State Patrol Retirement System (WSPRS) <br />- <br />Plan 1 <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 16of17