Please contact PEBA's Customer Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
SECTION I
CONTLENG
ENDINGDATE(REQUIRED)
MONTHSPAID
BEGINNINGDATE(REQUIRED)
DorN
SVC
PRV
NUM
STATE ORPWAGES
EMPLOYEE NAME
EMPLOYER CODE
EMPLOYER NAME
REASON FOR SUPPLEMENT:
Instructions are on Page 2.
Form 1227Revised 7/1/2023Page 1
Contact Person (please print)
Telephone
Date
Signature
(MM-DD-YYYY)
PORSMEMBERWAGES
PORS MEMBERCONTRIBUTIONS
SCRSMEMBERWAGES
SCRS MEMBERCONTRIBUTIONS
RETIREEINDICATOR"R"
SSN
SECTION 2 - EMPLOYER CONTRIBUTIONS
5. CHECK TOTAL (combine line 4 of SCRS, PORS and STATE ORP)
3. Accidental Death Program contributions (if covered) - PORS only (see Form 1340)
1. Employer retirement contributions Total wages x contribution rate (see Form 1340)
2. Incidental Death Benefit contributions (if covered)
Total wages x rate (see Form 1340)
4. Total remittance due (Section 1 total member contributions + line 1 + line 2 + line 3)
TOTALS
SUPPLEMENTAL CONTRIBUTION REPORT
SC Public Employee Benefit AuthorityPO Box 11960
Columbia, SC 29211-1960
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.
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