CSS2HTML: WEB6151P.XDP

"Disability applications are due by date terminated, but must be received by PEBA no later than 90 days after termination." If you are unable to complete this application, a designee (employer, legal counsel, power of attorney) may complete the application on your behalf, but may not complete method of payment or beneficiary information. Please see the reverse side for information about retirement effective dates.

Form 6151P
Revised 11/1/2017
Page 1

Section V

Section IV

Section II*

PERSONAL INFORMATION

Current/Former Employer(s)

PORS RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION

Section I      (Attach Your Birth Certificate)

PORS

PORS DISABILITY RETIREMENT APPLICATION
SC Public Employee Benefit Authority

202 Arbor Lake Drive

Columbia, SC 29223

YOUR PAYMENT PLAN MAY NOT BE CHANGED ONCE BENEFITS HAVE BEGUN AFTER RETIREMENT, except as noted on the reverse side.
If designating more than three beneficiaries, complete and attach an additional Form 6151P. 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. 

Check here if payments are to be paid through a trust and attach a completed Form 1113, Certification of Trust. 

Section III*

Relationship  (Check one)

Date of Birth

Social Security #/Federal ID#

1. Name of Beneficiary

Relationship  (Check one)

Date of Birth

Social Security #/Federal ID#

1. Name of Beneficiary

Relationship  (Check one)

Date of Birth

Social Security #

Social Security #

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

FOR DATES OF RETIREMENT OF JULY 1, 2005, OR AFTER

OFFICE USE ONLY

Social Security #

2. Name of Beneficiary 

Date of Birth

Social Security #

2. Name of Beneficiary 

Date of Birth

Relationship  (Check one)

Relationship  (Check one)

Relationship  (Check one)

Sex

Sex

Sex

Sex

Sex

Sex

Date of Birth

3. Name of Beneficiary 

3. Name of Beneficiary 

Your Position Title

Service application on file

TYPE OR PRINT IN BLUE INK

Date first eligible for

 disability retirement

MEMBER'S SIGNATURE                                                                                                                                           DATE

 

 

WITNESS                                                                                                                                                                   DATE

 EMPLOYMENT INFORMATION

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

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.

SIGNATURE STATEMENT

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

 (Required only when signed by mark) 

Correlated

Check
  One

If disability is the result of a job-related injury, check this box and attach employer's first report of injury form.

If receiving workers' compensation benefits check here.

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.

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

SOCIAL SECURITY NUMBER

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

FIRST/MIDDLE NAME

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.