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ATTACHMENT,,G" <br />RETIREMENT STATUS FORM <br />** All Contractors who are individuals must complete and sign ** <br />SECIION 1: CONTRACTOR COMPTETES 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 Pri <br />Signature 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 belowl <br />1. Has Contractor been a member of a Washington State Retirement System? <br />- <br />Yes <br />- <br />No <br />lf yes, which system and plan? <br />_Yes _ No <br />_Yes _ No <br />_Yes _ No <br />_Yes _ No <br />_ Teachers' Retirement System (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 Fighters' Retirement System (LEOFF) <br />_ Washington State Patrol Retirement System (WSPRS) <br />- <br />Plan 1 <br />_ Judicial Retirement System (JRS) <br />Plan 3 <br />Plan 3 <br />Plan 3 <br />Yes <br />Yes <br />_ Plan 1. _ Plan 2 <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 65 using the 2008 ERF? <br />I have verified the information above using MRV or by contacting DRS <br />COUNry REPRESENTATIVE (Please Print): <br />Signature:Date <br />COUNW RETAINS THIS FORM <br />Kittitas County Agreement for Services (rev.5/!4/25l' <br />Page 22 of 23