PAGE ____ OF ____

Use for designation of  beneficiaries and contingent beneficiaries. You may wish to consult with an attorney/estate planner before completing this form.

Contingent Beneficiaries Have No Rights Unless All Primary Beneficiaries Have Died

BENEFICIARY(IES) FOR REFUND OF CONTRIBUTIONS/SURVIVOR BENEFITS

BENEFICIARY(IES) FOR INCIDENTAL DEATH BENEFIT (You may not designate contingent beneficiaries for Incidental Death Benefit.)

5. Address

7. State

8. ZIP+4

Section II-A*

Section IV

Please read the instructions on the reverse (page 2) before completing this form.

PERSONAL INFORMATION

Section I

6. City

4. Date of Birth

1. Last Name & Suffix

2. First/Middle Name

3. Social Security Number

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.

Section II-B*

Relationship

Section III*

Retirement System (check one)

CHECK ONE:

Form 1103

Revised 11/1/2017

Page 1

Print or type in black ink

BENEFICIARY/TRUSTEE DESIGNATION FORM

SC Public Employee Benefit Authority

202 Arbor Lake Drive

Columbia, SC 29223

ALL SECTIONS MUST BE COMPLETED

CERTIFICATION AND CONDITIONS

I designate the following primary beneficiary(ies) to receive my Retirement Systems refund of contributions or survivor benefits: 

I designate the following beneficiary(ies) to receive my Retirement Systems Incidental Death Benefit:

Member's Signature

State of

Acknowledged before me this date

My Commission Expires

(Do not print)

Witness

(Required only when signed by mark)

County of

Notary Name

Notary Signature

(Out of state, requires Seal)

2. Name of Beneficiary (ONE PERSON) (without a trust)

Sex

Date of Birth

Social Security #

 1.  I certify that I desire to designate my Trust to receive my Retirement Systems benefits.  The name of my Trust (already in existence) is

Address of Trustee(s)

I certify that the following person will serve as the Trustee of my Trust after my death: 

My Trust Beneficiary(ies) is a live person.  I understand that in order for a survivor benefit to be paid, I or my Trustee(s) will be required to provide the excerpt of the Trust document reflecting all of the Trust beneficiaries.  Otherwise, only a lump sum benefit will be paid.

My Trust Beneficiary(ies) is not a live person.  I understand that only a lump sum benefit will be paid.

I designate the following contingent beneficiary(ies) to receive my Retirement Systems refund of contributions or survivor benefits: 

Relationship

Date of Birth

Sex

Social Security #

2. Name of Beneficiary (ONE PERSON) (without a trust)

My Trust Beneficiary(ies) is not a live person.  I understand that only a lump sum benefit will be paid.

My Trust Beneficiary(ies) is a live person.  I understand that in order for a survivor benefit to be paid, I or my Trustee(s) will be required to provide the excerpt of the Trust document reflecting all of the Trust beneficiaries.  Otherwise, only a lump sum benefit will be paid.

Address of Trustee(s)

I certify that the following person will serve as the Trustee of my Trust after my death: 

 1.  I certify that I desire to designate my Trust to receive my Retirement Systems benefits.  The name of my Trust (already in existence) is

Relationship

Date of Birth

Sex

2. Name of Beneficiary (ONE PERSON) (without a trust)

My Trust Beneficiary(ies) is not a live person.  I understand that only a lump sum benefit will be paid.

My Trust Beneficiary(ies) is a live person.  I understand that in order for a survivor benefit to be paid, I or my Trustee(s) will be required to provide the excerpt of the Trust document reflecting all of the Trust beneficiaries.  Otherwise, only a lump sum benefit will be paid.

Address of Trustee(s)

I certify that the following person will serve as the Trustee of my Trust after my death: 

 1.  I certify that I desire to designate my Trust to receive my Retirement Systems benefits.  The name of my Trust (already in existence) is

Social Security #

Dated

Dated

Dated

* 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.

Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.

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.