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ATTACHMENT'E" <br />RETTREMENT STATUS FORM (STGNATURE REQUIRED)-COUNW RETAINS THIS FORM <br />ALLCONTRACTORS, SERVICES CONTRACTORS, AND INDEPENDENT CONTRACTORS MUSTCOMPLETE 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 />2. ls the Contractor a retiree of a Washington State Retirement System? <br />3. Did the Contractor retire before age 65 using the 2008 ERF? <br />I have verified the information above using MRV or by contacting DRS <br />COUNTY REPRESENTATIVE (Please Print) <br />Date: <br />-x <br />Yes <br />Yes <br />Yes <br />Yes <br />YXx <br />No <br />No <br />No <br />No <br />CONTRACTOR (Full contractor as in DRS filings - Please print: Bill Clarke <br />Signature <br />j99t <br />Last Four Digits of Social Security No. <br />-Date: U w 2b <br />SECTION 2: COUNTY COMPLETES THIS SEGTION: <br />[Use Member Reporting Verification (MRV) to verify the past retirement membership and document below] <br />Contractor has been a member of the Washington State Retirement System? <br />-Yes - <br />No <br />lf yes, which system and plan? <br />_ Teacher's Retirement System (TRS) <br />-Plan <br />1 <br />- <br />Plan 2 <br />- <br />Plan 3 <br />_ School Employees' Retirement System (SERS) <br />- <br />Plan 2 <br />- <br />Plan 3 <br />_ Public Employees' Retirement Systems (PERS) <br />- <br />Plan 1- Plan 2 <br />- <br />Plan 3 <br />- <br />Public Safety Employees' Retirement System (PSERS) Plan 2 <br />-_ Law Enforcement Officers' & Firefighters' Retirement System (LEOFF) Plan2 <br />- <br />Plan 3 <br />- <br />Washington State Patrol Retirement System (WSPRS) <br />- <br />Plan 1 <br />-Plan <br />2 <br />-Judicial Retirement System (JRS) <br />Yes <br />Yes <br />No <br />No <br />Signature <br />COUNTY RETAINS THIS FORM <br />Page 16of17