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
FORWARD THIS FORM TO THE APPROPRIATE EMPLOYER FOR COMPLETION OF SECTION II.Please contact PEBA's Customer Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
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 service providers 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 Have you withdrawn your State ORP funds: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
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
DATES OF SERVICE
FROM
TO
Date:
Form 2130Revised 7/1/2023Page 1
Email Address
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