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SECTION 1: CONTRACTOR COMPLETES THIS SECTION: <br />DidyouretirefromoneoftheStateofWashingtonRetirementSystems? <br />Didyouretirebeforeage65usingthe2008earlyretirementfactors(ERF)? <br />Will you be receiving direct compensation for these services? <br />Will you be receiving indirect compensation for these services? <br />ATTACHMENT'G <br />SEIISE!4ISI-5IAIUI_EABU <br />** All Contractors who are individuals must complete and sign r* <br />2. ls Contractor a retiree of a Washington State Retirement System? <br />3.DidContractorretirebeforeage65usingthe200sERF? <br />I have verified the information above using MRV or by contacting DRS' <br />Yes <br />Yes <br />Yes <br />Yes <br />No <br />No <br />No <br />No <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Print): '- <br />Signature Last Four Digits of Social Security No <br />Date <br />SECTION 1: COUNTY COMPTETES THIS SECTION: <br />[Use Member Reporting Verification (MRV] to verify the past retirement membership and document belowl <br />1. Has contractor been a member of a washington state Retirement System? -- Yes -- No <br />lf yes, which sYstem and Plan? <br />Teachers' Retirement System (TRS) -_ Plan 1 Plan 2 <br />- <br />Plan 3 <br />: fi;;;oi"o*t;o"tiiu*unisvstem {stRs} - Plan 2 -. Plan 3 <br />- <br />Public Employees' Retirement Systerns (PERS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />- <br />Plan 3 <br />--- Public Safety Employees' Retirement System (PSERS) - <br />Plan 2 <br />-_ Law Enforcement officers, & Fire Fighters' Retirement system (lEOrr) - <br />Plan 1 - <br />Plan 2 <br />_ washington state patror Retirement system (wspRs) - Plan 1 <br />- <br />Plan 2 <br />Judicial Retirement SYstem (JRS) <br />Yes <br />Yes <br />No <br />No <br />COUNTY REPRESENTATIVE (Please Print): <br />Signature Date <br />COUNTY RETAINS ThIIS FORM <br />Kittitas County Agreement for Services {rev' 5/14/25) <br />Page 23 of 24