GENERAL ASSEMBLY RETIREMENT SYSTEM

SPECIAL CONTRIBUTING MEMBER ELECTION

SC Public Employee Benefit Authority

South Carolina Retirement Systems

Attention: SERVICE DEPARTMENT

P.O. Box 11960, Columbia, SC 29211-1960

Form 2140
Revised 7/6/2012
Page 1

Social Security Number

Address

Last Name & Suffix

First/ Middle Name

SECTION I

SECTION II

I hereby irrevocably elect to become a special contributing member of the General Assembly Retirement System (GARS)

as granted under Sections 9-9-40 and 9-9-120 of the SC Code of Laws.  I am aware that this written election must be

filed with the South Carolina Retirement Systems within six months from the cessation of my membership in the South

Carolina General Assembly.

I understand that, as a GARS special contributing member, the South Carolina Retirement Systems will invoice me

annually for payment of my GARS special contributing member contribution.  Further, I understand that if, in any given

year, I fail to directly remit payment for my GARS special contributing member contribution by no later than June 30th

after my invoice is received, that such nonpayment will be considered an irrevocable election on my part to end my GARS

special contributing member status.

Date

City

State

ZIP+4

Phone Number (Include Area Code)

General Assembly Term End Date

Signature