Laserfiche WebLink
ATTACHMENT "F,, <br />RETIREMENTSTATUS 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 forthese services? <br />CONTRACTOR (Full name of contractor as in DRS filings-Please Print):- <br />Signature:LastFourDigitsofSocialSecurity <br />Date <br />SECTION 1: COUNW 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 <br />- <br />No <br />lf yes, which system and plan? <br />- <br />Teachers' Retirement System (TRS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />- <br />Plan 3 <br />- <br />School Employees' Retirement System (SERS) <br />- <br />PIan 2 <br />- <br />Plan 3 <br />- Public Employees' Retirement Systems (PERS) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />- <br />Plan 3 <br />- <br />PublicSafetyEmployees'RetirementSystem(PSERS) - <br />Plan2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) <br />- <br />Plan 1 <br />- <br />Plan 2 <br />_ washington state Patrol Retirement system (wsPRs) _ Plan I <br />- <br />Plan2 <br />_ Judicial Retirement System (JRS) <br />Yes No <br />Yes _ No <br />Yes _ No <br />Yes No <br />2. ls Contractor a retiree 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 />Signatu D <br />COUNTY RETAINS THIS FORM <br />Kittitas County Agreement for Services (rev. 5lL4/251 <br />Page 19 of 19 <br />_Yes _ No <br />_Yes _ No