3.  I certify that there was no Trust Agreement in existence at the time of  _______________________________'s

death on ________________________. 

    PERSONALLY APPEARED before me, ________________________________________, who being duly sworn,

deposes and says:

    1.  I certify that I am the Trustee designated by  ________________________________________

(SSN______________________), 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 ________________________.

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 ___________________________________________

Retirement System
       (check one)          


SC Public Employee Benefit Authority

202 Arbor Lake Drive

Columbia, SC 29223

(Trustee Name)

(Member Name)

Form 4257
Revised 3/31/2017


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

(Member Name)