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. 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. If you elect a joint retiree-survivor plan, attach a birth certificate for each beneficiary designated. If designating more than three beneficiaries, complete and attach an additional Form 6101S. 

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 4/29/2021
Page 1

Sex

Current/Former Employer(s)

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

            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

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 90 days after, your service retirement effective date. 

1. Name of Beneficiary 

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

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

202 Arbor Lake Drive

Columbia, SC 29223

Section II*

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 Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.