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ATTACHMENT,,E,, RETIREMENT STATUS FORM ** All Contractors who are individuals must complete and sign ** SECTION 1: CONTRACTOR COMPTETES THIS SECTION: Did you retire from one of the State of Washington Retirement Systems? Did you retire before age 65 using the 2008 early retirement factors (ERF)? Will you be receiving direct compensation for these services? Will you be receiving indirect compensation for these services? 1. Has Contractor been a member of a Washington State Retirement System? lf yes, which system and Plan? Yes Yes Yes Yes N N N N o o o o CONTRACTOR (Full name of contractor as in DRS filings-Please Print) Signature Last Four Digits of Social Security No.- Date: SECTION 1: COUNTY COMPTETES THIS SECTION: [Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] Yes No - Teachers' Retirement System (TRS) - Plan 1 - Plan 2 - School Employees' Retirement System (SERS) - Plan 2 - Public Employees' Retirement Systems (PERS) - Plan L - Plan2 - Public Safety Employees' Retirement System (PSERS) - Plan 2 - Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) - Washington State Patrol Retirement System (WSPRS) - Plan 1 _ Judicial Retirement System (JRS) Plan 3 Plan 3 Plan 3 _ Plan 1 Plan 2 No Plan 2 2. ls Contractor a retiree of a Washington State Retirement System? 3. Did Contractor retire before age 65 using the 2008 ERF? I have verified the information above using MRV or by contacting DRS COUNTY REPRESENTATIVE (Please Print): Signature Date COUNTY RETAINS THIS FORM Kittitas County Agreement for Services (rev.5/L4/251 Page 19 of 19 Yes Yes No