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QUARTER ENDING

ADJUSTMENT TO QUARTERLY PAYROLL REPORT

EMPLOYER NAME

Form 1223
Revised 12/29/2017
Page 1
SEE INSTRUCTIONS ON REVERSE (PAGE 2)

EMPLOYER CODE#

SOCIAL SECURITY #

4

ADJUSTED TOTALS FOR THE QUARTER

EMPLOYEE

SCRS
MEMBER
CONTRIBUTIONS

PORS
WAGES

PORS
MEMBER
CONTRIBUTIONS

ORP
WAGES

MONTHS
PAID

SCRS
WAGES

RETIREE
INDICATOR
"R"

1

2

3

CONTACT PERSON (please write legibly)

7

8

10

11

CONTRACT
LENGTH

VENDOR
NUMBER

5

Telephone

SIGNATURE

6

Date

(MM-DD-YYYY)

SC Public Employee Benefit Authority
PO 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 Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.