CSS2HTML: WEB1224.XDP

SECTION II - EMPLOYER CONTRIBUTIONS

     Wages x Total Contribution Rate (see reverse/Page 2)

SECTION III - TOTAL DUE PER SYSTEM

     (Member Contributions + Employer Contributions)

SECTION IV - NET REMITTANCE (SCRS, PORS AND STATE ORP)

SOCIAL
SECURITY #

SCRS
WAGES

TOTALS

PORS
WAGES

CONT
LENG

VEN
NUM

D
or
N

Form 1224
Revised 12/29/2017
Page 1 of 2

EMPLOYER CODE # 

EMPLOYER NAME 

REASON

EMPLOYEE NAME

SERV
TYPE

SCRS
MEMBER
CONTRIBUTIONS

BEGINNING
DATE
(REQUIRED)

SIGNATURE

DATE

TELEPHONE

CONTACT PERSON (please write legibly)

(MM-DD-YYYY)

NOTE: Contributions remitted under the leave without pay status for service types 34, 59 & 61 are not subject to the insurance surcharge, Incidental Death

Benefit contributions, or accidental death contributions.

PORS
MEMBER
CONTRIBUTIONS

ORP
WAGES

ENDING
DATE
(REQUIRED)

SECTION I

SUPPLEMENTAL SERVICE REPORT

SC Public Employee Benefit Authority
PO Box 11960

Columbia, SC 29211-1960

SEE INSTRUCTIONS ON REVERSE (Page 2)

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.