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 EMPLOYMENT INFORMATION

SIGNATURE AND AUTHORIZATION

Section V

APPLICATION FOR SERVICE RETIREMENT BENEFITS

JUDGES AND SOLICITORS RETIREMENT SYSTEM (JSRS)

SC Public Employee Benefit Authority

202 Arbor Lake Drive

Columbia, SC 29223

SOCIAL SECURITY NUMBER

FIRST/MIDDLE NAME

LAST NAME & SUFFIX

PERSONAL INFORMATION

JSRS RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION

Section I     

         JSRS

    Attachments Required

OFFICE USE ONLY

Form 6101J
Revised 11/1/2017

Page 1

Date of Birth

Date of Birth

Social Security #

Date of Birth

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 Form 7204 (Direct Deposit Authorization). 

Section IV

Social Security #

Social Security #

2. Name of Beneficiary

3. Name of Beneficiary

2. Name of Beneficiary

Date of Birth

Social Security

Date of Birth

Social Security #

1. Name of Beneficiary 

Section II*

1. Name of Beneficiary 

Social Security #

Date of Birth

3. Name of Beneficiary 

Current
Position:

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
(choose one):

INCIDENTAL DEATH BENEFIT

Section III*

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.

MEMBER'S SIGNATURE ______________________________________________________________ DATE __________________________________                                                                                                                                                                 

 Indicate if you plan to irrevocably retire and continue working as authorized by statute [?9-8-60(7)]?

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Sex

Sex

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.

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.