CSS2HTML: WEB6100.XDP

MM-DD-YYYY

Service Credit at 
Retirement:

Years      Months      Days

Sick Leave Days:

Date

Signature of Member

I understand that the estimate of retirement benefits I will receive is only a projection based on the information I
have provided.  I further understand that receipt of the benefit estimate does not qualify me for retirement, does
not change any beneficiary(ies) I have previously designated, and does not certify my date of retirement,  retire-
ment service credit, or average final compensation.  I am fully aware that I should not leave employment based
on the uncertified information contained in this estimate. 

Average Final

Compensation:

        OR

Current Salary:

Average final compensation (AFC) is the average of your 12 highest
consecutive quarters of earnings (Jan.-Mar., Apr.-Jun.,Jul.-Sep., Oct.-
Dec.).  You may use your current salary if your estimated date of
retirement is at least three years away. To receive a conservative estimate of
benefits, please do not include final annual leave payments in your AFC.

4.  Date of
     Birth:

5.  Date of
     Birth:

6.  Date of
     Birth:

MM-DD-YYYY

MM-DD-YYYY

MM-DD-YYYY

MM-DD-YYYY

MM-DD-YYYY

MM-DD-YYYY

1.  Date of
     Birth:

2.  Date of
     Birth:

3.  Date of
     Birth:

PROJECTED BENEFICIARY INFORMATION

SECTION II

Home telephone:

Work telephone:

System:

Date of Birth:

Please change my official address to the one given above, and send the benefit estimate to that address.
Do not change my official address, but send the benefit estimate to the address given above.

To obtain an estimate of your monthly retirement benefits, please complete this request form and return it to the address
listed above.  This form cannot be used as an application for benefits.  A separate retirement application is required.

Social Security Number:

Zip + 4:

State:

City:

MEMBER INFORMATION

SECTION I

Address:

Type of Retirement:

SECTION III

PROJECTED RETIREMENT INFORMATION

Estimated Date of 
Retirement:

Choose one:

     Estate
     (proceed to Section III)


     Beneficiary(ies)
     (complete information at right)

 You may obtain a benefit estimate by calling SC Retirement Systems Customer Service at (800) 868-9002 (in state) or (803) 737-6800

Check here if listing more than six beneficiaries.  Please list additional beneficiaries on the back of this form.

    OR

REQUEST FOR RETIREMENT BENEFIT ESTIMATE

                     SC Public Employee Benefit Authority

                     South Carolina Retirement Systems

                    Box 11960, Columbia, SC 29211-1960

              ATTENTION: CUSTOMER ANNUITY CLAIMS 

Form 6100
Revised 4/20/2016

 

Print or type in black ink

First/Middle Name:

Last Name & Suffix:

Email Address: