SIGNATURE AND AUTHORIZATION
APPLICATION FOR SERVICE RETIREMENT BENEFITS
JUDGES AND SOLICITORS RETIREMENT SYSTEM (JSRS)
SC Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
JSRS RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION
OPTIONAL SURVIVOR (REDUCED) PAYMENT PLAN
STANDARD (MAXIMUM) PAYMENT PLAN
TYPE OR PRINT IN BLUE INK
Applications for retirement may be filed as early as six months prior to or up to 90 days after the effective retirement date.
If designating more than three beneficiaries, complete and attach an additional Form 6101J.
Payments are made by direct deposit. Please complete Direct Deposit Authorization (Form 7204).
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.
Please read the Authorization section of the instructions on the reverse (Page 2) before signing this form IN BLUE INK.
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.
THE OPTIONAL PAYMENT PLAN REQUIRES A COPY OF THE PROOF OF BIRTH FOR ALL BENEFICIARIES.
SELECT ONLY ONE MONTHLY PAYMENT PLAN.
Last day on payroll
will be or was:
Effective Date of Retirement
My signature indicates that I understand that it is my responsibility to contact PEBA or my health insurance provider regarding my eligibility for retiree health insurance, if applicable.
MEMBER'S SIGNATURE ____________________________________________________________ DATE ________________________________
Indicate if you plan to irrevocably retire and continue working as authorized by statute [?9-8-60(7)]?
Date of Birth (proof required)
Please contact PEBA's Customer Service 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.
THE LANGUAGE USED IN THIS DOCUMENT DOES NOT CREATE ANY CONTRACTUAL RIGHTS OR ENTITLEMENTS AND DOES NOT CREATE A CONTRACT BETWEEN THE MEMBER AND THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY. THE SOUTH CAROLINA PUBLIC EMPLOYEE BENEFIT AUTHORITY RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT.