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ATTACHMENT'F" <br />""N/A- Nor-Pac operates as an S Corp*" <br />RETIREMENT STATUS FORM <br />*+ All contractors who are indivHuals must complete and sign ** <br />SECIION 1: CONTRACTOR COMPLETES THIS SECIION: <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-faetors{ERF)? <br />Will you be receiving direct compensation for these services? <br />Will you be receiving indirect compensation for these services? <br />Teachers' Retirement Systern (TRS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />-School Employees' Retirement System (SERS) <br />- <br />Plan 2 <br />-Public Employees' Retirement Systems (PERS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />-Public Safety Employees' Retirement System (PSERS) <br />- <br />Plan 2 <br />Law Enforcement Officers' & Fire FighterJ Retirement System (LEOFF) <br />Washington State Patrol Retirement System (WSPRS) <br />- <br />Plan 1 <br />-Judicial Retirement System (JRS) <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />No <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Print) <br />Last Four Digits of Social Security No.- <br />Date: <br />SECTION 1: COUNW COMPLETES THIS SECIION: <br />[Use Member Reportlng Verlflcatlon (MRV] to verify the past retlrement membership and document belowl <br />1. Has Contractor been a member of a Washington State Retirement System? - <br />Yes <br />- <br />No <br />lf yes, which system and plan? <br />Plan 3 <br />Plan 3 <br />Plan 3 <br />_Plan1_Plan2 <br />Plan 2 <br />No <br />No <br />2. ls Contractor a retiree of a Washington State Retirement System? <br />3. Did Contractor retire before age 55 usingthe 2008 ERF? <br />I have verified the information above using MRV or by contacting DRS. <br />COUNTY REPRESENTATIVE (Please Print) <br />Sienature: Date: <br />COUNTY RETAI NS THIS FORM <br />Kittitas County Agreement for Services (rev. 5lt4lZ5l <br />Page 19 of 19