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The member must be off the payroll from all employment under South Carolina Retirement System, Police Officers Retirement System, or the State Optional Retirement Program as of the effective date of retirement.  Applications for retirement may be filed as early as six months prior to, and up to three months after, your service retirement effective date. 

MEMBER'S SIGNATURE                                                                                                                                           DATE


 

WITNESS                                                                                                                                                                   DATE

Section V

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.

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.

Specific
date:

Day following last
day on payroll 

Effective Date of Retirement
(choose one): 

Last day on payroll
will be or was:

Your Position Title

Current/Former Employer(s)

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 6101P. For all plans, attach a 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. 
           

OFFICE USE ONLY

Form 6101P
Revised 11/1/2017
Page 1

  (Certified copy of legal authorization required with signature other than applicant's)  

 PORS SERVICE RETIREMENT APPLICATION

 SC Public Employee Benefit Authority

202 Arbor Lake Drive
Columbia, SC 29223

 (Required only when signed by mark) 

 

Relationship  (Check one)

Date of Birth

Social Security #/Federal ID#

1. Name of Beneficiary

Relationship  (Check one)

Section II*

Date of Birth

Social Security #/Federal ID#

1. Name of Beneficiary

Relationship  (Check one)

Date of Birth

Social Security #

2. Name of Beneficiary 

Date of Birth

Social Security #

3. Name of Beneficiary 

Date of Birth

Social Security #

2. Name of Beneficiary 

Social Security #

3. Name of Beneficiary 

Date of Birth

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Sex

Sex

Sex

Sex

Sex

Sex

SIGNATURE  STATEMENT

           INCIDENTAL DEATH BENEFIT
CHECK IF SAME BENEFICIARY(IES) AS IN SECTION II        

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

 EMPLOYMENT INFORMATION

PORS RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION

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

Check here if payments are to be paid through a trust

and attach a completed Certification of Trust (Form 1113).   
  

Section III*

Section IV

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

* 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.

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

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.