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ATTACHMENT "E" <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 of the State of Washington Retirement Systems? — Yes ^ No <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? — Yes _ No <br />Will you be receiving direct compensation for these services? — Yes _ No <br />Will you be receiving indirect compensation for these services? - _ Yes No <br />CONTRACTOR (Full name of contractor as in DRS filings -Please Print): <br />Signature: <br />Date: <br />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 below] <br />1. Has Contractor been a member of a Washington State Retirement System? _ Yes _ No <br />If yes, which system and plan? <br />_ Teachers' Retirement System (TRS) _ Plan 1 _ Plan 2 _ Plan 3 <br />_ School Employees' Retirement System (SERS) _ Plan 2 _ Plan 3 <br />Public Employees' Retirement Systems (PERS) _ Plan 1 _ Plan 2 _ Plan 3 <br />Public Safety Employees' Retirement System (PSERS) _ Plan 2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) —Plan 1 _ Plan 2 <br />Washington State Patrol Retirement System (WSPRS) _ Plan 1 _ Plan 2 <br />Judicial Retirement System (JRS) <br />2. Is Contractor a retiree of a Washington State Retirement System? —Yes _ No <br />3. Did Contractor retire before age 65 using the 2008 ERF? _ Yes , No <br />I have verified the information above using MRV or by contacting DRS. <br />COUNTY REPRESENTATIVE (Please Print): <br />Signature: Date: <br />COUNTY RETAINS THIS FORM <br />Kittitas County Agreement for Services (rev. 5/14/25) <br />Page 19 of 19 <br />