SC Public Employee Benefit AuthorityPO Box 11960
Columbia, SC 29211-1960
Form 1221Revised 12/29/2017Page 1SEE INSTRUCTIONS ON REVERSE (PAGE 2)Print or type in black ink
STANDARD RETIREMENT QUARTERLY REPORT
(MM-DD-YYYY)
SOCIAL SECURITY #
SCRS CONTRIBUTIONS
PORSWAGES
PORS CONTRIBUTIONS
6
MONTHSPAID
ACCOUNTING
TOTAL ALL PAGES
PAGE TOTALS
3
EMPLOYER:
4
5
7
8
9
SCRSWAGES
RETIREEINDICATOR"R"
CONTRACTLENGTH
2
Page of
Ending Date
Beginning Date
Employer Code No.
EMPLOYEE
1
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.
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