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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? <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? <br />Will you be receiving direct compensation for these services? <br />Will you be receiving indirect compensation for these services? <br />CONTRACTOR (Full name of contractor as in DRS filings -Please Print): <br />Signature: <br />Da te: <br />Last Four Digits of Social Security No, <br />Yes No <br />Yes No <br />Yes No <br />Yes 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) J 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 <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 f 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 23 of 24 <br />Plan 2 <br />