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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)

Social Security #

Social Security #

Relationship

Relationship

Section IV

Section I

4. Date of Birth

Relationship

PERSONAL INFORMATION

CERTIFICATION AND CONDITIONS

Section III

3. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

Social Security #

Relationship

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:

1. Name of Beneficiary (ONE PERSON)

Social Security #

Social Security #

2. Name of Beneficiary (ONE PERSON)

3. Name of Beneficiary (ONE PERSON)

Social Security #

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 7/6/2012

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

South Carolina Retirement Systems

P.O. Box 11960, Columbia, SC 29211-1960

 

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

Sex

Sex

Sex

Sex

Sex

Sex

Sex

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)

Relationship

Date of Birth

Relationship

Date of Birth

Date of Birth

Date of Birth

Date of Birth

Relationship

Relationship

Relationship

2. Name of Beneficiary (ONE PERSON)

1. Name of Beneficiary (ONE PERSON)

Date of Birth

Date of Birth

Date of Birth

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 RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.