CHECK ONE:
5. Address
BENEFICIARY(IES) FOR REFUND OF CONTRIBUTIONS/SURVIVOR BENEFITS - I designate the following
PRIMARY beneficiary(ies) to receive my Retirement Systems refund of contributions or survivor benefits if eligible.
7. State
ALL SECTIONS MUST BE COMPLETED
2. Name of Beneficiary (ONE PERSON)
8. ZIP+4
Social Security #
Section II-A*
1. Name of Beneficiary (ONE PERSON)
3. Name of Beneficiary (ONE PERSON)
Relationship
Section IV
Section I
4. Date of Birth
PERSONAL INFORMATION
CERTIFICATION AND CONDITIONS
Section III*
Date of Birth
BENEFICIARY(IES) FOR INCIDENTAL DEATH BENEFIT (You may not designate contingent beneficiaries for the Incidental Death
Benefit). I designate the following beneficiary(ies) to receive my Retirement Systems Incidental Death Benefit:
Use for designation of active member beneficiaries and contingent beneficiaries. You may wish to consult with an attorney/estate planner before completing this form.
PAGE ____ OF ____
6. City
Please read the instructions on the reverse (Page 2) before completing this form.
Form 1102
Revised 11/1/2017
Page 1
Print or type in black ink
ACTIVE MEMBER BENEFICIARY FORM
BENEFICIARY DESIGNATION, CONTINGENT BENEFICIARY FOR
ACTIVE MEMBERS ONLY- RETIREES USE FORM 7201
SC Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
MEMBER'S SIGNATURE ______________________________________________ WITNESS _____________________________________________ STATE OF ___________________________________________________________ COUNTY OF __________________________________________Acknowledged before me this date ________________________________ NOTARY NAME _______________________________________________My Commission Expires ________________________________ NOTARY SIGNATURE __________________________________________________
Retirement System (check one)
Section II-B*
1. Last Name & Suffix
3. Social Security Number
2. First/Middle Name
Contingent Beneficiaries Have No Rights Unless All Primary Beneficiaries Have Died - I designate the following CONTINGENT beneficiary(ies) to receive my Retirement Systems refund of contributions or applicable survivor benefits. If the contingent beneficiary designation below is blank all previous contingent beneficiaries will be revoked and your estate will become your contingent beneficiary.
Sex
IMPORTANT: Please read the Certification and Conditions sections of the instructions on the reverse (Page 2) before signing this form. I hereby certify I have read and understand the information on the reverse (Page 2), including the certification and conditions, and I agree to the provisions stated.
(Do not print) (Required only when signed by mark)
(Out of state, requires Seal)
* YOUR BENEFICIARY DESIGNATIONS WILL NOT BE REVOKED UNDER SECTION 62-2-507 OF THE SOUTH CAROLINA CODE OF LAWS BY
DIVORCE, ANNULMENT, OR ORDER TERMINATING MARITAL PROPERTY RIGHTS.
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 SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY. THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.
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