EMPLOYER CERTIFICATION OF POLICE OFFICERS RETIREMENT SYSTEM (PORS) ELIGIBILITY
Form 1107Revised 11/1/2017
SC Public Employee Benefit Authority202 Arbor Lake Drive
Columbia, SC 29223
6. I certify that as a
5. I certify that in his/her capacity of
3. I certify that
4. I certify that
2. That in my capacity as
1. I am the
, who being duly sworn,
PERSONALLY APPEARED before me,
deposes and says:
, I am familiar with the duties and responsiblities of the
is a participating employer in the Police
Officers Retirement System;
is an employee of
and currently holds the position
, he/she is required by the terms
of their employment to give time to: a) the preservation of public order, the protection of life and property and the detection of crimes; or b) the prevention and control of property destruction by fire.
, he/she is required to devote at least 1,600 hours
per year of active duty performing the "police officer" or "fireman" duties listed in paragraph 5 above, and that he/she receives at least $2,000 salary per year for these duties in accordance with Section 9-11-40(4) or Section 9-1-660.
EMPLOYER'S SIGNATURE __________________________________________________ (Do not print) STATE OF ________________________________________________ COUNTY OF_______________________________________________ACKNOWLEDGED BEFORE ME THIS DATE _______________________ NOTARY NAME _________________________________________MY COMMISSION EXPIRES _________________________ NOTARY SIGNATURE _______________________________________________ (Out of state requires Seal)
This form must be completed for any PORS member other than a magistrate or a probate judge.
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.
Scripting must be enabled for this form to work correctly.