CSS2HTML: WEB2130.XDP

REQUEST FOR STATE ORP SERVICE VERIFICATION

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 and Suffix

First/ Middle Name

Social Security Number

Address

A separate form must be completed for each employer verification.

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:

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 vendors you used for your State Optional

Retirement Program (State ORP) account:

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 Have you withdrawn your State ORP funds: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 PUBLIC EMPLOYEE BENEFIT AUTHORITY.  THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY 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 5/17/2019
Page 1

Email Address