EMPLOYER:
Form 1222Revised 12/29/2017Page 1SEE INSTRUCTIONS ON REVERSE (PAGE 2)Print or type in black ink
STANDARD RETIREMENT QUARTERLY REPORT - CLASS I EMPLOYER
SC Public Employee Benefit AuthorityPO Box 11960
Columbia, SC 29211-1960
Page of
Quarter End Date
Quarter Begin Date
Employer Code No.
(MM-DD-YYYY)
MONTHSPAID
PORS CIWAGES
PORS CIIWAGES
SCRS CONTRIBUTIONS
RETIREEINDICATOR"R"
TOTAL ALL PAGES
PAGE TOTALS
EMPLOYEE
1
SOCIAL SECURITY #
PORS CII CONTRIBUTIONS
PORS CI CONTRIBUTIONS
2
3
4
5
6
7
8
9
10
11
SCRSWAGES
ACCOUNTING
CONTRACTLENGTH
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.
Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
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