CSS2HTML: WEB2130.XDP

REQUEST FOR STATE ORP SERVICE VERIFICATION

(Applies to State ORP Service in South Carolina only)

SC Public Employee Benefit Authority

202 Arbor Lake Drive

Columbia, SC 29223

Print or type in black ink.

SECTION I:  MEMBER INFORMATION (TO BE COMPLETED BY THE MEMBER)

Last Name & Suffix

First/ Middle Name

Social Security Number

Address

A separate form must be completed for each employer verification to be made.

City

ZIP+4

Work Telephone

Home Telephone

Employer Name

Address

City

ZIP+4

 FORWARD THIS FORM TO THE APPROPRIATE EMPLOYER FOR COMPLETION OF SECTION II.
Please call PEBA's Customer Contact Center with any questions: 803.737.6800 or 888.260.9430.

5. LIST ANY ADDITIONAL EMPLOYER(S) FOR WHICH YOU ARE SEEKING TO OBTAIN VERIFICATION:

6. ADDITIONAL COMMENTS THAT MAY HELP IN VERIFYING THIS SERVICE (IF ANY):

1. LIST THE EMPLOYER NAME, ADDRESS AND DATES OF SERVICE:

2. FULL NAME AT TIME SERVICE WAS RENDERED, IF DIFFERENT FROM ABOVE:

3. PLEASE CHECK THE VENDOR(S) YOU UTILIZED FOR YOUR

    STATE OPTIONAL RETIREMENT PLAN:

4. HAVE YOU WITHDRAWN YOUR STATE ORP FUNDS?

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.

IF NO, DO YOU INTEND TO PURCHASE YOUR STATE ORP SERVICE WITH:

Member Signature:                                           

State

State

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 RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT

Year

Day

Month

Year

Day

Month

DATES OF SERVICE

FROM

TO

Date:

Form 2130
Revised 4/19/2016
Page 1

Email Address