QUARTER ENDING
ADJUSTMENT TO QUARTERLY PAYROLL REPORT
EMPLOYER NAME
Form 1223Revised 7/1/2023Page 1SEE INSTRUCTIONS ON REVERSE (PAGE 2)
EMPLOYER CODE
SOCIAL SECURITY #
4
ADJUSTED TOTALS FOR THE QUARTER
EMPLOYEE
SCRS MEMBERCONTRIBUTIONS
PORSWAGES
PORS MEMBERCONTRIBUTIONS
STATE ORPWAGES
MONTHSPAID
SCRSWAGES
RETIREEINDICATOR"R"
1
2
3
CONTACT PERSON (please write legibly)
7
8
10
11
CONTRACTLENGTH
SERVICE
PROVIDER
NUMBER
5
Telephone
SIGNATURE
6
Date
(MM-DD-YYYY)
SC Public Employee Benefit AuthorityPO Box 11960
Columbia, SC 29211-1960
TOTALS FROM REPORT
9
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 Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
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