Form 3229
Revised 7/11/2012
Page 1 of

TOTALS

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. 

                          SSN

             DEFERRED
              (PRE-TAX)
            DEDUCTION
               AMOUNT

      NON DEFERRED
         (AFTER TAX)
          DEDUCTION
             AMOUNT

                                       EMPLOYEE NAME

EMPLOYER CODE #:

EMPLOYER NAME:

TOTAL REMITTANCE:

PAYROLL END DATE:

INSTALLMENT SERVICE PURCHASE REMITTANCE

SC Public Employee Benefit Authority
South Carolina Retirement Systems
Box 11960, Columbia, SC 29211-1960