MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE                                                                                                                       
                             
WITNESS                                                                                                                                                                                 

STATE OF                                                                                                      COUNTY OF

ACKNOWLEDGED BEFORE ME THIS DATE                                       NOTARY NAME

MY COMMISSION EXPIRES                                                                 NOTARY SIGNATURE

NOTARY BUSINESS PHONE                                                                                                                                                               

Section II  Tax withholding information  (Applicable for any taxable portion paid directly to you.)

Section I   For your refund payout, please select ONE of the payment methods below. (See Page 2 for detailed explanation.)  

REFUND REQUEST

SC Public Employee Benefit Authority

Customer Service Refund Claims

202 Arbor Lake Drive

Columbia, SC 29223

Mailing Address

City

Former/Maiden Name (if applicable)

CHECK ONE:

Pay the total Single Sum Payment directly 

to you (less required federal tax withholding).

For direct deposit see Page 2.

       Choose ONE of the following:

Section III     Complete this section if you selected a direct or partial rollover above.

Account Number With Trustee/Plan (Limited to 25 characters)

P.O. Box or Street Address

You must attach a legible copy of your current driver's license or special
identification card issued by your state Department of Transportation or Public Safety.

By executing this form I am requesting a refund of my account balance in the retirement system selected above. I understand that by receiving this refund, I am cancelling my membership in the selected retirement system; forfeiting all of my service credit in that system; and waiving any right or interest I have in that system, including giving up all rights to any future service or disability retirement benefits in that system. 

I certify that I have read and understand the information provided on this form, including the information on the reverse side and in the attached rollover notice, and I agree to the terms stated.

(Certified copy of legal authorization required with signature other than applicant's)  

 (Please print)

Please call PEBA's Customer Service with any questions: 803.737.6800 or 888.260.9430.

 (Required only when signed by a mark) 

DATE

DATE

Social Security Number

Date of Birth

First/Middle Name

Last Name & Suffix

Telephone Number

ZIP+4

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 PUBLIC EMPLOYEE BENEFIT AUTHORITY.  THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

Please complete form

in blue or black ink.

Direct Rollover

Rollover the Partial Amount of

Account Types Available (Check only ONE Box)

Consult trustee to determine plan type as necessary.

The remaining balance will be paid directly to you in a single sum payment, less federal tax withholding.  For direct deposit, see Page 2.

Section IV  Signature and Notary Statement -- Form must be notarized to be accepted. 

Form 4101

Revised 1/5/2024

Page 1

MM/DD/YYYY

Email Address

South Carolina state income tax: If you do not complete this section, no state taxes will be withheld.