RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION

TYPE II:  100%-100% JOINT RETIREE-SURVIVOR

TYPE III: 100%-50% JOINT RETIREE-SURVIVOR

TYPE I:  RETIREE ONLY ANNUITY

Relationship  (Check one)

Relationship  (Check one)

I hereby certify I have read and understand the information on the reverse side (Page 2), including the authorization, and I agree to the terms stated.

Which of the following positions do you currently hold or have you held in the past (check all that apply)?

Please read the Authorization section of the instructions on the reverse (Page 2) before signing this form IN BLUE INK.

Date of Birth

Date of Birth

Date of Birth

Social Security #

Social Security #

Social Security #/Federal ID#

Sex

Sex

Relationship  (Check one)

Relationship  (Check one)

3. Name of Beneficiary 

2. Name of Beneficiary

1. Name of Beneficiary 

Date of Birth

Date of Birth

Date of Birth

Social Security #

Social Security #

Social Security #/Federal ID#

Sex

Sex

Sex

Relationship  (Check one)

Relationship  (Check one)

3. Name of Beneficiary 

2. Name of Beneficiary

1. Name of Beneficiary 

Sex

EMPLOYMENT INFORMATION

INCIDENTAL DEATH BENEFIT

MEMBER'S SIGNATURE 

DATE                                                                                                                                            

Applications for retirement may be filed as early as six months prior to, and up to three months after, the effective date. The member must be off the payroll as of the effective date of retirement. 

Section II*

Form 6101G
Revised 11/1/2017
Page 1

OFFICE USE ONLY

APPLICATION FOR SERVICE RETIREMENT BENEFITS
GENERAL ASSEMBLY RETIREMENT SYSTEM (GARS)

SC Public Employee Benefit Authority
202 Arbor Lake Drive

Columbia, SC 29223

My signature indicates that I understand that it is my responsibility to contact my employer or health insurance provider regarding my eligibility for retiree health insurance, if applicable.

 Indicate if you plan to irrevocably retire and continue working as authorized by statute [?9-9-60(3)].

YOUR PAYMENT PLAN MAY NOT BE CHANGED ONCE BENEFITS ARE FIRST PAYABLE, except as noted on the reverse side.

If designating more than three beneficiaries, complete and attach an additional Form 6101G.  For all plans, attach a copy of your birth certificate. Each plan requires a legible copy of your birth certificate and your current driver's license or special identification card issued by your state department of transportation or public safety. For any joint retiree-survivor plan, attach your beneficiary's birth certificate. SELECT ONLY ONE MONTHLY ANNUITY PAYMENT PLAN.

Payments are made by direct deposit. Please complete Form 7204 (Direct Deposit Authorization).  

Section IV

Section III*

SOCIAL SECURITY NUMBER

PERSONAL INFORMATION

Section I      (Attach Your Birth Certificate)

LAST NAME & SUFFIX (Jr., Sr., etc.)

FIRST/MIDDLE NAME

TYPE OR PRINT IN BLUE INK

Address

Date of Birth (proof required)

Sex

City

State

ZIP+4

Home Phone

Work Phone

Email Address

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

* YOUR BENEFICIARY DESIGNATIONS WILL NOT BE REVOKED UNDER SECTION 62-2-507 OF THE SOUTH CAROLINA CODE OF LAWS BY

  DIVORCE, ANNULMENT, OR ORDER TERMINATING MARITAL PROPERTY RIGHTS.