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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

Attention: Enrollment

202 Arbor Lake Drive

Columbia, SC 29223

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

Form 1162

Revised 1/17/2018

 

 

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: