1. *Employee completes this section:
    2. Employer completes this section:
    State of Washington
    Department of Retirement Systems
    Retirement Status Form
    Employer retains the form.
    *Employee completes this section:
    Employee Name_______________________________________________ SSN_____________________________
    (Please print)
    Retired means receiving a lifetime, defined benefit. Members who are only separated or who are only receiving Plan 3
    defined contributions do not meet the retiree definition.
    Q1.
    Are you retired from one of the Washington State Retirement Systems?
    Yes
    No
    Q2.
    Are you retired or have you ever been a member of the Seattle, Spokane or Tacoma
    Employees’ Retirement System?
    Yes
    No
    Q3.
    Are you currently employed by another public employer and contributing to a Washington
    State Retirement System?
    Yes
    No
    Signature of employee
    Date
    Employer completes this section:
    Question 1:
    If the employee answered "yes," and is:
    ??
    Returning to Active Service:
    The retiree's benefit may be impacted. Don't report until you contact Employer Support
    Services (ESS).
    ??
    A Retiree Returning to Work (RRTW)
    : Verify that the employee is a retiree; then report as a RRTW.
    Question 2:
    If the employee answered "yes," contact ESS.
    Question 3:
    If the employee answered "yes," contact ESS if you need assistance determining the correct system and plan.
    If the employee answered "no" to all three questions,
    use Member Reporting Verification (MRV) to verify the employee's past
    retirement history. Record any prior membership below, then report the employee in the correct system and plan.
    Document prior retirement membership using MRV:
    Has the employee ever been a member of a Washington State Retirement System?
    Yes
    No
    If yes, what system and plan?
    Teachers’ Retirement System
    Plan 1
    Plan 2
    Plan 3
    School Employees’ Retirement System
    Plan 2
    Plan 3
    Public Employees’ Retirement System
    Plan 1
    Plan 2
    Plan 3
    Public Safety Employees' Retirement System
    Plan 2
    Law Enforcement Officers’ and Fire Fighters’ Retirement System
    Plan 1
    Plan 2
    Washington State Patrol Retirement System
    Plan 1
    Plan 2
    Judicial Retirement System
    Is the employee a retiree of a Washington State Retirement System?
    Yes
    No
    I have verified the information above using MRV or by contacting a DRS representative.
    _____________________________________________________________
    Signature of employer
    Date
    *RCW 41.50.139 requires employers to solicit in writing the retiree status of all new employees.
    DRS
    DRS MS
    MS 147
    147 (Rev.6/06)
    (Rev. 6/05)

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