Form 1104Revised 10/22/2013Page 1
ELECTION OF NON-MEMBERSHIP
SC Public Employee Benefit Authority
South Carolina Retirement SystemsAttention: EnrollmentBox 11960, Columbia, SC 29211-1960
3. Social Security Number
1. Last Name & Suffix (PLEASE PRINT)
2. First/Middle Name (PLEASE PRINT)
I understand that 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), who is not receiving benefits as a retired member, may elect to participate in either the traditional defined benefit plan, SCRS, or the optional defined contribution plan, State ORP. The election to participate in State ORP must be made within 30 calendar days after entry into service (date of hire).
I hereby notify you that I am an employee of the state of South Carolina or its political subdivisions, and that I meet the requirements to elect non-membership in the Retirement Systems, and I hereby exercise my option to elect non-membership.
I take this action under the provisions of the Retirement Act with full knowledge that I will not be credited with retirement service for this period of employment since I have elected non-membership.
I also certify that the information provided in items 1-12 of Section I of this form are true to the best of my knowledge and belief.
9. Date of Birth
10. Date of Employment
11. Position Title
12. Present Monthly Salary
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.
Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800
Print or type in black ink and sign in blue ink. Please read the instructions on Page 2 before completing this form.
Non-membership Qualification Reason
EMPLOYMENT CATEGORY (TO BE COMPLETED BY THE EMPLOYER)
If the employee's position qualifies him or her to elect non-membership, please mark the appropriate box. If an employee currently has funds on deposit in the Retirement Systems, the employee may not elect non-membership. See Instructions on page 2 for more information.
I hereby certify that the employee listed in items 1-2 of Section I of this form meets the requirements to elect non-membership.
Optional Membership - Exemptions authorized by the Retirement Act
Elected official earning $9,000 or less per year
Employee earning less than $2,000 in salary or working fewer than 1,600 hours in a year as a police officer or fireman cannot participate in PORS. (If employer is covered under SCRS, employee may elect to enroll as member of SCRS.)
Individual serving in General Assembly while retired under JSRS or receiving GARS benefits at age 70 or after 30 years service
If you currently have funds on deposit in the Retirement Systems, you may not elect non-membership.
Retired Justice/Judge returning to work for public institution of education
EMPLOYEE CERTIFICATION AND SIGNATURE
Individual first elected to serve in the General Assembly after general election of 2012
Scripting must be enabled for this form to work correctly