(Required only when signed by mark)
25. I hereby certify that the employee listed in Section I of this form is eligible for the retirement plan selected.
16. Select State ORP Vendor
1. Last Name & Suffix
SECTION I: EMPLOYEE INFORMATION (TO BE COMPLETED BY THE EMPLOYEE)
Form 1100Revised 10/22/2013Page 1
Print or type in black ink and sign in blue ink.
Please read the instructions on Page 2 before completing this form.
9. Date of Birth
SECTION II: EMPLOYER INFORMATION (TO BE COMPLETED BY THE EMPLOYER)
19. Employer Name
20. Please indicate if you are the employee's primary or secondary employer.
24. Employee's Annual Salary
23. Employee's Position Title
22. Date of Membership
10. Telephone Number
17. 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 annual 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 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 15 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.
14. Are you now receiving or have you applied to receive a monthly benefit from any of PEBA's retirement systems?
Did you withdraw your contributions?
12. If item 11 is "Yes", indicate the name(s) of your former employer:
13. Do you currently have a pending refund request?
2. First/ Middle Name
11. Have you ever been a member of the PEBA's retirement systems?
21. Original Date of Hire with Employer listed in Items 18-19
ACTION REQUESTED (Check One):
15. Retirement Plan Election (CHOOSE ONE)
For more information, please contact Customer Services at 803-737-6800, 800-868-9002 (within S.C. only), or www.retirement.sc.gov
18. Employer Code
Work Telephone Number
NEW ENROLLEE (First-time membership)
OPEN ENROLLMENT (Irrevocable election from State ORP)
CHANGE OF EMPLOYER (Transfer)/DUAL EMPLOYMENT
CHANGE OF INFORMATION
Name (Prior Name):
SSN (Old Number):
Date of Birth
PORS (See Instructions)
State ORP (If State ORP, please complete item 16.)
JSRS - Judge (001.00)
JSRS - Solicitor (002.00)
JSRS - Circuit Public Defender (003.00)
Application in Process
RETIREMENT PLAN ENROLLMENT
S.C. Public Employee Benefit Authority
Box 11960, Columbia, SC 29211-1960
3. Social Security Number
(attach copy of Social Security card only if changing SSN)
(ATTACH LEGAL DOCUMENT INDICATING NAME CHANGE
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