PERSONALLY APPEARED before me,                                                                         , who being duly sworn,

deposes and says:

    1.  I certify that I am a Successor Trustee named in a Trust created 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)

SUCCESSOR TRUSTEE CERTIFICATION

            State Budget and Control Board

           South Carolina Retirement Systems

          Box 11960, Columbia, SC 29211-1960

d. Name of Beneficiary 

c. Name of Beneficiary

Date of Birth

Date of Birth

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 ___________________________________________
                                                                                                                                                                 

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

a. Name of Beneficiary

b. Name of Beneficiary

Date of Birth

Date of Birth

Social Security #

Social Security #

Social Security #

Social Security #

Form 4258
Revised 03/13/2003