PERSONALLY APPEARED before me,                                                                                 , who being duly sworn,

    deposes and says:

    1.  I certify that I am the Trustee designated by  

    (                                          ), to receive his/her South Carolina Retirement Systems benefits to hold in trust for the

    benefit of certain beneficiaries.

    

    2.  My mailing address is, 

    and my telephone number is

    3.  I certify that the following person(s) are beneficiary(ies) of the trust:

Retirement System
     (check one)

TRUSTEE'S SIGNATURE ____________________________________     WITNESS _______________________________________________
   (Certified copy of legal authorization required with signature other than applicant's)                   (Required only when signed by mark)

STATE OF ______________________________________________       COUNTY OF_____________________________________________

ACKNOWLEDGED BEFORE ME THIS DATE ____________________      NOTARY NAME _________________________________________

MY COMMISSION EXPIRES __________________________     NOTARY SIGNATURE ___________________________________________
                                                                                                                                                                 

Social Security #

Social Security #

Social Security #

Social Security #

d. Name of Beneficiary 

c. Name of Beneficiary

Date of Birth

Date of Birth

a. Name of Beneficiary

b. Name of Beneficiary

Date of Birth

Date of Birth

Form 4256
Revised 03/13/2003

CERTIFICATION OF TRUST - DEATH CLAIMS

               State Budget and Control Board

               South Carolina Retirement Systems

              Box 11960, Columbia, SC 29211-1960

Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800