EMPLOYER CERTIFICATION OF POLICE OFFICERS
          RETIREMENT SYSTEM (PORS) ELIGIBILITY

Form 1107
Revised 11/1/2017

SC Public Employee Benefit Authority
202 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 

of 

;

, who being duly sworn, 

PERSONALLY APPEARED before me, 

deposes and says:

, I am familiar with the duties and responsiblities of the

employees of

is a participating employer in the Police 

Officers Retirement System;

(SSN#                                     )

is an employee of 

and currently holds the position

of 

;

, 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.