CSS2HTML: WEB1222.XDP

EMPLOYER:

Form 1222
Revised 12/29/2017
Page 1
SEE INSTRUCTIONS ON REVERSE (PAGE 2)
Print or type in black ink

STANDARD RETIREMENT QUARTERLY REPORT - CLASS I EMPLOYER

SC Public Employee Benefit Authority
PO Box 11960

Columbia, SC 29211-1960

Page              of

Quarter End Date

Quarter Begin Date

Employer Code No.

(MM-DD-YYYY)

MONTHS
PAID

PORS CI
WAGES

PORS CII
WAGES

SCRS
CONTRIBUTIONS

RETIREE
INDICATOR
"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

SCRS
WAGES

ACCOUNTING

CONTRACT
LENGTH

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.