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MEMBER'S SIGNATURE                                                                                                                       DATE

 

 

WITNESS                                                                                                                                               DATE

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 6101S.  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. 
           

SOCIAL SECURITY NUMBER

PERSONAL INFORMATION

Social Security #

Date of Birth

Social Security #/Federal ID#

Date of Birth

Section III

1. Name of Beneficiary 

2. Name of Beneficiary

Social Security #

3. Name of Beneficiary

Social Security #

Date of Birth

2. Name of Beneficiary

Sex

Social Security #/Federal ID#

Date of Birth

Section I      (Attach Your Birth Certificate)

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

OFFICE USE ONLY

SCRS RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION

Form 6101S
Revised 8/24/2012
Page 1

Sex

Current/Former Employer(s)

Do you plan to defer your retirement benefits through the Teacher and Employee Retention Incentive (TERI) program?

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.

FIRST/MIDDLE NAME

SCRS

TYPE OR PRINT IN BLUE INK

Disability pending

TERI Participant

            SIGNATURE  STATEMENT

Date of Birth

Social Security #

3. Name of Beneficiary 

Sex

Sex

Sex

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

Specific
date:

Day following last
day on payroll 

Effective Date of Retirement
(choose one): 

Check here if payments are to be paid through a trust

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

Sex

Correlated

Date of Birth

 EMPLOYMENT INFORMATION

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

Last day on payroll
will be or was:

Your Position Title

 (Required only when signed by mark) 

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

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 month prior to, and up to three months after, your service retirement effective date. 

1. Name of Beneficiary 

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 RETIREMENT SYSTEMS.  THE SOUTH CAROLINA RETIREMENT SYSTEMS RESERVES THE RIGHT TO REVISE THE CONTENT OF THIS DOCUMENT. 

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.

Please contact Customer Services with any questions: 803-737-6800, 800-868-9002 (within S.C. only), or www.retirement.sc.gov.

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

Section IV

Section V

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Address

Date of Birth (proof required)

Sex

City

State

ZIP+4

Home Phone

Work Phone

 SCRS SERVICE RETIREMENT APPLICATION

SC Public Employee Benefit Authority

South Carolina Retirement Systems

P.O. Box 11960, Columbia, SC 29211-1960

 

Section II