(Required only when signed by mark)
26. I hereby certify that the employee listed in Section I of this form is eligible for the retirement plan selected.
17. Select State ORP Service Provider
SECTION I: EMPLOYEE INFORMATION (TO BE COMPLETED BY THE EMPLOYEE)
Print or type in black ink.
Please read the instructions on Page 2 before completing this form.
SECTION II: EMPLOYER INFORMATION (TO BE COMPLETED BY THE EMPLOYER)
21. Please indicate if you are the employee's primary or secondary employer.
25. Employee's Annual Salary
24. Employee's Position Title
18. An employee hired by an eligible employer (school district, higher education, technical college, state department, agency, bureau, commission, and institution) covered under the South Carolina Retirement System (SCRS), or individuals first elected to the S.C. General Assembly in and after November 2012, may elect to participate in either the traditional defined benefit plan, SCRS, or the optional defined contribution plan, State Optional Retirement Program (State ORP). The election to participate in State ORP must be made within 30 calendar days after entry into service (date of hire).
If I do not make an election within the required time, I will be considered to have elected membership in SCRS. Participants in the State ORP assume all investment risk. The election to participate in State ORP is irrevocable, except a State ORP participant may make a one-time irrevocable election to join SCRS during any open enrollment period after the first anniversary, but before the fifth annual anniversary of the initial enrollment in State ORP.
I understand that, unless a designated beneficiary is on file, my estate will be designated as my beneficiary until PEBA and/or my selected State ORP service provider receives from me a properly executed beneficiary form.
My signature below indicates that my employer has explained the retirement plan options available to me and has provided me with access to information necessary to make an informed choice. My signature on this document confirms my retirement plan election as indicated in block 16 above.
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE PUBLIC EMPLOYEE BENEFIT AUTHORITY. THE PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
15. Are you now receiving or have you applied to receive a monthly benefit
Did you withdraw your contributions?
14. Do you currently have a pending refund request?
22. Original Date of Hire with Employer listed
in Items 19-20
ACTION REQUESTED (Check One):
16. Retirement Plan Election (CHOOSE ONE)
12. Have you ever been a member of PEBA's retirement systems?
13. If item 12 is "Yes," indicate the name(s) of your former employer:
RETIREMENT PLAN ENROLLMENT
S.C. Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
3. Social Security Number
(ATTACH LEGAL DOCUMENT INDICATING NAME CHANGE)
(attach copy of Social Security card only if changing SSN)
from any of PEBA's retirement systems?
Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.