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ATTACHMENT'F" <br />RETIREMENT ATUS 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? <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 />1". Has Contractor been a member of a Washington State Retirement System? <br />lf yes, which system and plan? <br />Yes <br />Yes <br />Yes <br />Yes <br />t/ No <br />vNo <br />VNo <br />r/ No <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Pri nt) <br />Signature Last Four Digits of Social Security N <br />Date <br />SECTION 1: COUNTY COMPLETES THIS SECTION: <br />[Use Member Reporting Verification (MRV] to verify the past retirement membership and document belowl <br />Bur."\q\tsrq, <br />-J) <br />-\s\e <br />Yes _ No <br />_ Teachersa,Retirement System (TRS) _ plan 1 _ plan 2 <br />_ School Employees' Retirement System (SERS) _ plan 2 <br />_ Public Employees' Retirement Systems (PERS) _ Plan 1 _ plan 2 <br />_ Public Safety Employees' Retirement System (PSERS) _ Plan 2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) <br />_ Washington State Patrol Retirement System (WSPRS) _ Plan 1 <br />_ Judicial Retirement System (JRS) <br />Plan 3 <br />Plan 3 <br />Plan 3 <br />_ Plan L _ Plan 2 <br />Plan 2 <br />2. ls Contractor a retlree of a Washington State Retirement System? <br />3. Did 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 />Signature Date <br />COUNTY RETAINS THIS FORM <br />Kittitas County Agreemqnt for Services (rev.5/741251 <br />Page 19 of 19 <br />Yes <br />Yes <br />_No <br />_No