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SECTION I

CONT
LENG

ENDING
DATE
(REQUIRED)

MONTHS
PAID

BEGINNING
DATE
(REQUIRED)

D
or
N

VEN
NUM

ORP
WAGES

EMPLOYEE NAME

EMPLOYER CODE #

EMPLOYER NAME

REASON FOR SUPPLEMENT:

SEE INSTRUCTIONS ON REVERSE (Page 2)

Form 1227
Revised 12/29/2017
Page 1

CONTACT PERSON (please write legibly)

Telephone

Date

SIGNATURE

(MM-DD-YYYY)

PORS
MEMBER
WAGES

PORS
MEMBER
CONTRIBUTIONS

SCRS
MEMBER
WAGES

SCRS
MEMBER
CONTRIBUTIONS

RETIREE
INDICATOR
"R"

SSN

SECTION 2  - EMPLOYER CONTRIBUTIONS

5. CHECK TOTAL (combine line 4 of SCRS, PORS and STATE ORP)

3. Accidental death 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 Authority
PO 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.