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ATTACHMENT'E" RETIREMENT STATUS FORM * * All contractors who are individuals must complete and sign ** SECTION 1: CONTRACTOR COMPLETES THls SECTION: 2'lsContractoraretireeofaWashingtonStateRetirementSystem? 3. Did Contractor retire before age 65 using the 2008 ERF? I have verified the information above using MRV or by contacting DRS' COUNTY REPRESENTATIVE (Please Print) Signature Date: COUNTY RETAINS THIS FORM Kittitas County Agreement for Services trev' 5lM/25) Page 19 of 19 DidyouretirefromoneoftheStateofWashingtonRetirementSystems? Did you retire before age 65 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 - No _Yes - No *Yes - No _Yes - No CoNTRACTOR (Full name of contractor as in DRS filings-Please Print): Signatu Last Four Digits of Social Security No'-. - SECTION 1: COUNTY COMPLETES 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 Systern? - Yes - No lf yes, which system and Plan? - Teachers' Retirement System (TRS) - Plan 1 - PIan 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 - - Washington State Patrol Retiremeni System (WSPRS) - Plan 1 - Plan 2 Judicial Retirement SYstem (JRS) Plan 2 Yes Yes No No