Form 1226
Revised 8/20/2015
 

State:

ZIP+4:

This authority is to remain in full force and effect until the South Carolina Retirement Systems has received written notification from me (us) of its termination in such time and in such manner as to afford the South Carolina Retirement Systems and the financial institution indicated above a reasonable opportunity to act on it.

As required by Title 9 of the South Carolina Code of laws, payment of retirement contributions
will be initiated from the above bank account on the designated due date as indicated on
forms 1244 and 1246.  Forms must be received by 12:00 P.M. on the last business day before
the due date.  Forms received after this date will be considered late and debited the next business day.  Delinquent payments require an interest assessment.  Forms can be mailed in the green
Accounting Department envelope or faxed to 803-740-1255.

Employer Name: 

Employer Code:

Financial Institution: 

Branch:

City: 

Transit/ABA Number : 

(9 positions)

Account Number:

(Please Print)

Title:

Date:

Authorization Agreement for Automatic Debits

SC Public Employee Benefit Authority

South Carolina Retirement Systems

P.O. Box 11960

Columbia, SC 29211-1960 

Contact Name:

financial institution named below, to debit and/or credit the same to such account.

savings account (select one) and the 

checking

entries and adjustments for any debit entries in error to our

I (we) hereby authorize the South Carolina Retirement Systems  to initiate debit entries and to initiate, if necessary, credit