Section II Tax Withholding Information (Applicable for any taxable portion paid directly to you.)
MEMBER'S OR ALTERNATE PAYEE'S SIGNATURE
STATE OF COUNTY OF
ACKNOWLEDGED BEFORE ME THIS DATE NOTARY NAME
MY COMMISSION EXPIRES NOTARY SIGNATURE
NOTARY BUSINESS PHONE
I do hereby apply for a refund of the total amount of contributions plus interest credited to me in the retirement system selected above. I understand that upon payment of such amount I do hereby waive for myself, my heirs, and assigns all my rights, title, and interest in any fund under the care and control
of this retirement system. I also understand that by receiving a refund that I am forfeiting my service credit and giving up all rights to any future service retirement or disability retirement benefits based on this service. I further understand that my refund request will be canceled if I return to employment covered by the Retirement Systems prior to payment of my refund. This includes any employment for which I am eligible to join the SC Retirement System, the Police Officers Retirement System, or the State Optional Retirement Program. The SC Code of Laws prohibits payment for a refund of contributions any earlier than 90 days from your date of separation from covered employment.
Section I For your refund payout, please select ONE of the payment methods below. (See Page 2 for detailed explanation.)
SC Public Employee Benefit Authority
Customer Service Refund Claims
202 Arbor Lake Drive
Columbia, SC 29223
Former/Maiden Name (if applicable)
Pay the total Single Sum Payment directly
to you (less required federal tax withholding).
Payment must be directly deposited -- 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 (Limit 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.
Please read all information on Page 2 before signing this form.
I hereby certify that I have read and understand the information on this form, including the tax rules, and I agree to the terms stated.
(Certified copy of legal authorization required with signature other than applicant's)
Please call PEBA's Customer Contact Center with any questions: 803.737.6800 or 888.260.9430.
(Required only when signed by a mark)
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.
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.
in addition to the required 20 percent federal tax calculation.
for South Carolina state income tax.
Section IV Signature and Notary Statement -- Form must be notarized to be accepted.