CSS2HTML: WEB2122.XDP

Form 2122

Revised 4/19/2016

Page 1

 

Please Print or

Type in Black Ink

REQUEST FOR PUBLIC/EDUCATIONAL SERVICE VERIFICATION

SC Public Employee Benefit Authority

Retirement Benefits Service Department

202 Arbor Lake Drive

Columbia, SC 29223

PART I - MEMBER INFORMATION - To be completed by the member.  A separate form must be completed for each employer verification to be made.

Social Security Number:

Last Name & Suffix (Sr., Jr., etc.): 

First Name/Middle Name:

Date of Birth:

Address:       

Zip+4:

7.  Indicate any additional employer(s) for which you are seeking to obtain service verification other than that listed above:

State:

5. Did you contribute to a retirement/pension plan?

3. Position/Title

4.  Was this service full time?

2. Full name at time service was rendered, if different from above: 

1. List the employer name, address and dates of service:

If "yes", give name of plan:

From

To

MM        DD        YYYY

City:

MM        DD        YYYY

Employer Name:

Address:

Zip:

State:

City: 

Telephone:

Work:

Home:

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

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.

 

PLEASE FORWARD THIS FORM TO THE EMPLOYER FROM WHICH YOU ARE SEEKING VERIFICATION TO COMPLETE PART II .

I hereby request and authorize the release of the information requested on this form and any additional information necessary to document this claim for service.

6. Additional comments that may help in verifying this service (if any):

Member Signature:

Date:

Email Address: