Fully Executed Agreement - Laserfiche WebLink

Home Browse Search

ATTACHMENT "F" RETIREMENT STATUS FORM ** All Contractors who are individuals must complete and sign ** SECTION 1: CONTRACTOR COMPLETES THIS SECTION: Did you retire from one of the state of washington Retirement systems? Did you retire before age 55 using the 2008 early retirement factors (ERF)? Will you be receiving direct compensation for these services? will you be receiving indirect compensation for these services? Yes Yes Yes Yes No No No No CONTRACTOR (Full name of contractor as in DRS filings-Please Print):- Signatu re Last Four Digits of Social Security N Date: SECTION 1: COUNTY COMPTETES THIS SECTION: [Use Member Reporting Verification (MRV) to verify the past retirement membership and document belowl 1. Has Contractor been a member of a Washington State Retirement System? - Yes - No lf yes, which system and Plan? Teachers' Retirement System (TRS) - Plan L - Plan 2 - Plan 3 School Employees' Retirement System (SERS) - Plan 2 - Plan 3 public Employees, Retirement systems (PERS) - Plan 1 - Plan 2 - Plan 3 Public Safety Employees' Retirement System (PSERS) - Plan 2 Law Enforcement officers' & Fire Fighters' Retirement system (LEOFF) - Plan 1 - Plan 2 Washington State Patrol Retirement System (WSPRS) - Plan I - PlanZ Judicial Retirement SYstem (JRS) 2. ls contractor a retiree of a washington state Retirement system? 3. Did Contractor retire before age 55 using the 2008 ERF? I have verified the information above using MRV or by contacting DRS. COU NTY REPRESENTATIVE (Please Print):- Signature Date COUNW RETAINS THIS FORM Kittitas County Agreement for Services (rev.5/74/251 Page2L of 22 _ Yes Yes No _No