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ATTACHMENT'T' <br />RETIREMENT STATUS FORM <br />** All Contractors who are individuals must complete and sign ** <br />SECTION 1; CONTRACTOR COMPLETES THIS SECTION: <br />Did you retire from one ofthe State ofWashington Retirement Systems? Yes No <br />Did you retire before age 65using the 200early retirement factoo(EKF)? _Yes No <br />Will you 6ereceiving direct compensation for these services? _Yes No <br />Will you bereceiving indirect compensation for these services? Yes No <br />CONTRACTOR (Full name ofcontractor asinQRSfilings-Please 9rint): <br />7 <br />SignatureJ Last Four Digits ofSocial Security No. <br />SECTION 1- COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV) toverify the past retirement membership and document below] <br />1.Has Contractor been amember ofaWashington State Retirement System? _ Yes _Wo <br />If yes, which system and plan? <br />__ Teachers' Retirement System (TRS) __PlanI <br />Plan <br />Plan <br />__ School Employees' Retirement System (SERS) <br />Plan <br />Plan <br />__ Public Employees' Retirement Systems (PEBS) P|anl <br />Plan <br />Plan <br />__ Public Safety Employees' Retirement System (PSERS) <br />Plan <br />__ Law Enforcement Officers' &k Fire Fighters' Retirement System (LEOFF) <br />1 Plan 2 <br />__ Washington State Patrol Retirement System (VVSPRS) <br />Plan l <br />__P|am __ <br />Plan 2 <br />__ Judicial Retirement System (JRS) <br />2�bContractor aretiree ufaWashington State Retirement System? __ Yes No <br />3. Did Contractor retire before age 6Susing the 20O8ERF? Yes No <br />| have verified the information above using MRVorbycontacting DRS. <br />COUNTY REPRESENTATIVE (Please Pri <br />Date: <br />COUNTY RETAINS THIS FORM <br />KhdtasCounty Agreement for Services <rev 5/I4/25) <br />Page 19of 20 <br />