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 #
SCRSWAGES
TOTALS
PORSWAGES
CONTLENG
SVC
PRV
NUM
DorN
Form 1224Revised 10/30/2023Page 1 of 2
EMPLOYER CODE
EMPLOYER NAME
REASON
EMPLOYEE NAME
SERVTYPE
SCRS MEMBERCONTRIBUTIONS
BEGINNINGDATE(REQUIRED)
SIGNATURE
DATE
TELEPHONE
CONTACT PERSON (please write legibly)
(MM-DD-YYYY)
NOTE: Contributions remitted under the leave without pay status for service type 34, 59 & 61 are not subject to the insurance surcharge, Incidental Death Benefit contributions, or Accidental Death Program contributions.
PORS MEMBERCONTRIBUTIONS
STATE ORPWAGES
ENDINGDATE(REQUIRED)
SECTION I
SUPPLEMENTAL SERVICE REPORT
SC Public Employee Benefit AuthorityPO 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.
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