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ATTACHMENT'G" 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)? Willyoubereceivingdirectcompensationfortheseservices? Will you be receiving indirect compensation for these services? Yes Yes Yes Yes No No No No coNTRACTOR (Full name of contractor as in DRS filings-Please Print): Signature Last Four Digits of Social Security No Date SECTION 1: COUNTY COMPLETES THIS SECTION: [Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] 1. Hascontractorbeenamemberof aWashingtonStateRetirementSystem? -Yes - No lf yes, which sYstem and Plan? - Teachers' Retirement System (TRS) - Plan 1 - Plan 2 - Plan 3 - School Employees' Retirement System (SERS) - Plan 2 - Plan3 - Public Employees' Retirement Systems (PERS) - Plan 1 - Plan 2 - Plan 3 Public Safety Employees' Retirement System (PSERS) - Plan 2 _ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) - Plan 1 - - Washington State Patrol Retirement System (WSPRS) - Plan 1 - Plan 2 - Judicial Retirement System (JRS) 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' COUNTV REPRESE NTATIVE (Please Print):- Signature Date: COUNTY RETAINS THIS FORM Kittitas County Agreement for Services (rev' 5/La/251 Page23 of 23 Plan 2 Yes Yes No No