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ATTACHMENT “F” <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 Plan 2 __ Plan 3 <br /> School Employees’ Retirement System (SERS) Plan 2 __ Plan 3 <br /> Public Employees’ Retirement Systems (PERS) Plan 1 Plan 2 __ Plan 3 <br /> Public Safety Employees’ Retirement System (PSERS) ___________ Plan 2 <br /> Law Enforcement Officers’ & Fire Fighters’ Retirement System (LEOFF) Plan 1 ___ Plan 2 <br /> Washington State Patrol Retirement System (WSPRS) Plan 1 ___ Plan 2 <br /> Judicial Retirement System (JRS) <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