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SECTION I                                                                   EMPLOYEE INFORMATION

SECTION II                                                            REASON FOR CHANGE

STATE OPTIONAL RETIREMENT PROGRAM (STATE ORP)

NOTICE OF TERMINATION OR CHANGE

SC Public Employee Benefit Authority

South Carolina Retirement Systems

Attention: Enrollment

Box 11960, Columbia, SC 29211-1960

1. Last Name & Suffix 

3. Social Security Number

2. First/Middle Name   

6.  State 

7.  Zip + 4 

4. Address

5. City

9. Current Vendor Name

SECTION III                                   TO BE COMPLETED BY EMPLOYEE AND EMPLOYER

                                 Return completed form to the SC Public Employee Benefit Authority Systems (see address above)
                                     Please call Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800.

Form 1162

Revised 12/16/2014

 

 

Print or type in

black ink

8. Email Address

Effective Date:

New Vendor:

Effective Date:

Effective Date:

Employer Code:

Employer Name:

Employee's Signature:

Date:

Telephone:

Authorized Employer Signature: