CSS2HTML: WEB2209.XDP

     Service Purchase Salary Verification

      SC Public Employee Benefit Authority

   South Carolina Retirement Systems

PO Box 11960, Columbia SC 29211-1960

803-737-6800 or 800-868-9002 (within SC only) 

 

Form 2209
Revised 7/14/2015

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. 

Agency Name and Address:

The employee named above has submitted a request to purchase additional service credit.  In order to calculate the payment required, we must have salary and employee status information as requested below. Current annual salary includes base salary plus any additional compensation subject to retirement withholdings (i.e. overtime pay, summer school, additional course load, differentials, stipends, coaching supplement).

I certify the base annual salary during fiscal year (20_____-20_____) for this

 

employee to be $_______________________________________________________

Date

Telephone Number

Re:

Employee Name 

SSN#

I certify this employee will also earn additional compensation during

 

fiscal year (20_____-20_____) in the amount of $_____________________________

 

for__________________________________________________________________                               (Indicate reason for additional payment)

Signature

Title

Employer Code

I certify the current status of this employee to be:   (check applicable box)

supplemental contributions due to:  (check applicable box) 

(NOTE: If the employee worked on an intermittent or as-needed basis, please provide the actual amount of compensation earned from July 1 through the current date.)