CSS2HTML: WEB2101.XDP

(OFFICE USE ONLY) Verification Forms Provided to Member:

Please call PEBA's Customer Contact Center with any questions: 803.737.6800 or 888.260.9430.

Member Signature:

As an active member of one of the retirement plans administered by PEBA, you may be entitled to purchase additional service credit.  By completing this form and returning it to the address above, you are initiating the process to purchase service credit.  Upon receipt of all necessary documentation, eligibility will be determined, and you will be informed by mail of the status of your request.

M=Male
F=Female

Service request taken:

Comments or Special Instructions:

Please provide a letter from your current employer(s) verifying current annual salary. *(see Page 2 of form)

Form 2101
Revised 4/19/2016
Page 1

 

Print or Type in Black Ink

REQUEST FOR SERVICE PURCHASE COST

SC Public Employee Benefit Authority

Retirement Benefits Service Department

202 Arbor Lake Drive

Columbia, SC 29223

Check if applying for Service and/or Disability Retirement Benefits

Date of Retirement: (mm-dd-yyyy)

Date(s) of Injury

System(s) in which you are currently contributing:

State:

- *Number of Forms:

- *Number of Forms:

- *Number of Forms:

 - Specify Amount of Service: 

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 PUBLIC EMPLOYEE BENEFIT AUTHORITY.  THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.

(Type of Service)

(MM-DD-YY)

(YY-MM-DD)

ZIP+4:

Please check the appropriate box(es) for service to be established.  PLEASE REFER TO THE DEFINITIONS AND

    INSTRUCTIONS ON THE BACK OF THIS FORM FOR INFORMATION PERTAINING TO YOUR REQUEST.

                         

 

Address:       

Last Name & Suffix (Sr., Jr., etc.):

First Name/Middle Name:


Social Security Number:

Member's full name during period of service to be established:

City:

Home Telephone:

Sex:

Date of Birth:

Work Telephone:

List Current Employer(s):

*Additional forms and instructions will be provided upon receipt of this completed form.

 Note: To establish public, educational, and/or State ORP service, please specify the number of forms needed.

 You must complete a separate form for each employer verification to be made.

 

Email Address