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SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />DidyouretirefromoneoftheStateofWashingtonRetirementSystems? <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 />Willyoubereceivingindirectcompensationfortheseservices? <br />ATTACHMENT "G" <br />RETIREMENT STATUS FORM <br />** All contractors who are individuals must complete and sign ** <br />coNTRACTOR (Full name of contractor as in DRS filings-Please Print) <br />Signature Last Four Digits of Social Security No' <br />Date <br />Plan 2 <br />Signature Date <br />COUNTY RETAINS THIS FORM <br />Kittitas County Agreement for Services {rev' 5/M/251 <br />Page22 of 23 <br />No <br />No <br />No <br />No <br />_Yes _ <br />Yes <br />_Yes _ <br />Yes <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? <br />-Yes - <br />No <br />lf Yes, which system and Plan? <br />- <br />Teachers' Retirement System (TRS) - <br />Plan 1 <br />- <br />Plan 2 <br />- <br />Plan 3 <br />- <br />School Employees' Retirement System (SERS) - <br />Plan 2 <br />- <br />Plan 3 <br />- <br />Public Employees' Retirement Systems (PERS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />- <br />Plan 3 <br />- <br />Public Safety Employees' Retirement System (PSERS) <br />- <br />Plan 2 <br />- <br />Law Enforcement officers' & Fire Fighters' Retirement system (LEOFF) <br />- <br />Plan 1 <br />- <br />Washington State Patrol Retiremeni System (WSPRS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />- <br />iudicial Retirement System (JRS) <br />2. lscontractora retireeofawashingtonstate Retirementsystem? -Yes - <br />No <br />3.Didcontractorretirebeforeage65usingthe2008ERF?-Yes-No <br />I have verified the information above using MRV or by contacting DRS' <br />COUNTY REPRESENTATIVE (Please Print):