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ATTACHMENT "E" <br />RETIREMENT STATUS 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? Yes _ No <br />Did you retire before age 65 using the 2008 early retirement factors (ERF)? Yes No <br />Will you be receiving direct compensation for these services? Yes No <br />Will you be receiving indirect compensation for these services? Yes 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 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 _ No <br />If yes, which system and plan? <br />_ Teachers' Retirement System (TRS) —Plan 1 <br />Plan 2 <br />Plan 3 <br />_ School Employees' Retirement System (SERS) <br />_ _ <br />_ Plan 2 <br />Plan 3 <br />_ Public Employees' Retirement Systems (PERS) _ Plan 1 <br />_ <br />Plan 2 <br />Plan 3 <br />_ Public Safety Employees' Retirement System (PSERS) <br />_ _ <br />Plan 2 <br />_ Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) <br />_ <br />1 Plan 2 <br />_ Washington State Patrol Retirement System (WSPRS) <br />_ Plan 1 <br />—Plan _ <br />Plan 2 <br />_ Judicial Retirement System (JRS) <br />_ <br />2. Is Contractor a retiree of a Washington State Retirement System? ` Yes _ No <br />3. Did Contractor retire before age 65 using the 2008 ERF? Yes No <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 Agreement for Services (rev. 5/14/25) <br />Page 19 of 19 <br />