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ATTACHMENT "G" <br />RETIREMENT STATUS FORM <br />** All Contractors who are individuals must complete and sign ** <br />SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />Did you retire from one of the State of Washington Retirement Systems? _ Yes _ No <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? _ Yes ` No <br />Will you be receiving direct compensation for these services? , Yes _ No <br />Will you be receiving indirect compensation for these services? , Yes _ No <br />CONTRACTOR (Full name of contractor as in DRS filings -Please Print): <br />Signature: <br />Date: <br />Last Four Digits of Social Security No. <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br />1. Has Contractor been a member of a Washington State Retirement System? _ Yes — No <br />If yes, which system and plan? <br />Teachers' Retirement System (TRS) —Plan 1 _ Plan 2 _ Plan 3 <br />School Employees' Retirement System (SERS) _ Plan 2 _ Plan 3 <br />Public Employees' Retirement Systems (PERS) _ Plan 1 _ Plan 2 _ Plan 3 <br />_ Public Safety Employees' Retirement System (PSERS) _ Plan 2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) _ Plan 1 _ Plan 2 <br />Washington State Patrol Retirement System (WSPRS) _ Plan 1 _ Plan 2 <br />Judicial Retirement System (JRS) <br />2. Is Contractor a retiree of a Washington State Retirement System? ^ Yes _ No <br />3. Did Contractor retire before age 65 using the 2008 ERF? —Yes _ No <br />I have verified the information above using MRV or by contacting DRS. <br />COUNTY REPRESENTATIVE (Please Print): <br />Signature: Date: <br />COUNTY RETAINS THIS FORM <br />Kittitas County Agreement for Services (rev. 5/14/25) <br />Page 22 of 23 <br />