BENEFICIARY'S SIGNATURE _______________________________________________     DATE ____________________________________________

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

WITNESS ______________________________________________________________     DATE _____________________________________________

                                  (Required only when signed by mark)

STATE OF ______________________________________________________      COUNTY OF ______________________________________________

ACKNOWLEDGED BEFORE ME THIS DATE ________________________     NOTARY NAME ______________________________________________

MY COMMISSION EXPIRES ____________________________     NOTARY SIGNATURE __________________________________________________

NOTARY WORK TELEPHONE ____________________________________

TYPE OF COVERAGE
       


     Bene.               

Form 4151

Revised 11/7/2022

Page 1

Print or type in blue or black ink

Name of Decedent:

Beneficiary's Name:

Relationship to Decedent:

SECTION II

Beneficiary's Social Security Number:

City:

SECTION I 

Address for Mailing Payment(s): 

Phone Number:

State:

Zip+4:

of

SIGNATURE AND NOTARY

*INCIDENTAL DEATH BENEFIT

**ESTIMATED MONTHLY SURVIVOR
   ANNUITY PAID FOR REMAINING
   LIFETIME OF BENEFICIARY

Active Member 

Retired Member 

Pre-Tax Funds 

After-Tax Funds 

Service Retirement

Disability Retirement

SIGN IN BLUE INK

DEATH BENEFIT PAYMENT ELECTION

See Page 2 for a detailed explanation of death benefit payment selections. All amounts are estimates.

 *You must complete the enclosed tax forms if you receive the Incidental Death Benefit or a payout of contributions and interest.

**You must complete the enclosed Form 7204 if you are eligible for and elect to receive a lifetime monthly annuity.

Please choose ONE of the death benefit payment selections by marking the appropriate box.

ELECTION OF DEATH BENEFITS

SC Public Employee Benefit Authority

Customer Service Death Claims

202 Arbor Lake Drive

Columbia, SC 29223

*PAYOUT OF CONTRIBUTIONS
  AND INTEREST

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. 

PAYMENT
SELECTION 3

PAYMENT
SELECTION 2

PAYMENT
SELECTION 1

Return completed form to SC PEBA (see address above)

Please contact PEBA's Customer Contact Center with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.

Decedent's Social Security Number: