3. I certify that there was no Trust Agreement in existence at the time of _______________________________'sdeath 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 forthe benefit of certain beneficiaries.
2. My mailing address is _________________________________________________, and my telephone numberis ________________________.
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)
CERTIFICATION OF NONEXISTENT TRUST
SC Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
Form 4257Revised 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.
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