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ATTACHMENT "E" <br />RETIREMENTSTATUS FORM <br />+ * All contractors who are individuals must Gompl€te and sign +* <br />SECTION 1: CONTRACTOR COMPLEIESTHIS SECTIoN: <br />Did you retire from one of the State of Washington Retirement Systems? <br />Didyouretirebeforeage65usingthe2003earlyretirementfactors(ERF)? <br />Will you n" ,.."iuing direct compensation for these-serv:t",:.t <br />Will you be receivinB indirect compensation for these services? <br />Yes No <br />No <br />No <br />No <br />Yes <br />Yes <br />Yes <br />CONTRACTOR (Fult name of contractor as in DRS filings-Please Print): <br />Signature:Last Four Digits of Social Security No' <br />Date: <br />rrr$T,,[,:-"#]ff9]|lfJ,"T,tlliilT:],n" o"..retirement membership and document berowt <br />1, Has contractor been a member of a washington state Retirement system? - <br />Yes - <br />No <br />lf Yes, which sYstem and Plan? <br />-. Teachers, Retirement system (TRs) - <br />Plan 1 - <br />Plan 2 - Plan 3 <br />- <br />School Employees' Retirement System (SERS) Plan 2 - <br />Plan 3 <br />- <br />Public Employees'RetirementSv't"tntipfni) -Plan <br />1 <br />- <br />Plan 2 - <br />Plan 3 <br />- <br />Public safety Employees' Re-tirym1nt system (PSERs) - - <br />Plan 2 <br />* Law rntorcemeni Officers, a rire figf,t"rs' Reiirement System (Leorrt Plan 1 - <br />Plan 2 <br />_ washington state patrol Retirem"ni svra"r (wspRs) - <br />Plan 1 - Plan 2 <br />Judicial Retirement Systern (JRS) <br />2'lscontractoraretireeofaWashingtonstateRetirementSystem?-Yes_No <br />3. Did Contractoruetiruietore age Si using the 2008 ERF? - <br />Yes - No <br />I have verified the information above using MRV or by contacting DRS' <br />COUNW REPRESENTATIVE ( Please Print) <br />Signature Date <br />COUNTY RETAINS THIS FORM <br />Kittitas county Agreement for Services lrev' 5/l4l25l <br />Page 19 of 19