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I <br />ATTACHMENT "F" <br />RETIREMENT STATUS FORM <br />* * All contractors who are individuals must complete and sign *r <br />SECNON 1: CONTRACTOR COMPIFTES 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 />Willyou be receiving indirect compensation for these services? <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 />COUNW REPRESENTATIVE (Please Print) : <br />Signatu <br />COUNTY RETAINS THIS FORM <br />Kittitas County Agreement for Services lrev. 5lL4l25l <br />Page 28 of 28 <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 <br />SECTION 1: COUNTY COMpLETES THIS SECTION: <br />[Use Member Reponing Verificatlon (MRVI to verlfy the past retirement membershlp and document belowl <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'RetirementSystem (TRS) - <br />Plan 1 <br />- <br />Plan 2 - <br />Plan 3 <br />- <br />School Employees' Retirement System (SERS) - Plan 2 - Plan 3 <br />_ Public Employees' Retirement systems (PERS) _ Plan 1 <br />- <br />Plan 2 - Plan 3 <br />- <br />Public Safety Employees' Retirement System (PSERS) - <br />Plan 2 <br />Law Enforcement Officers' & Fire Fighters' Retirement System (LEOFF) - <br />Plan 1 <br />- <br />Plan 2 <br />_ Washington State Patrol Retirement System (WSPRS) - Plan 1 - <br />Plan 2 <br />- <br />Judicial Retirement System (JRS) <br />Yes _ No <br />Yes No