MEMBER'S SIGNATURE DATE
Disability applications are due by termination date, but must be received by PEBA no later than one year 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 payment method or beneficiary information. Please see the reverse side for information about retirement effective dates.
SCRS DISABILITY RETIREMENT APPLICATION
SC Public Employee Benefit Authority
202 Arbor Lake Drive
Columbia, SC 29223
Service application on file
Date first eligible for
TYPE OR PRINT IN BLUE INK
SCRS RETIREMENT PLAN ELECTION AND BENEFICIARY DESIGNATION
Section I (Attach Your Birth Certificate)
Check here if payments are to be paid through a trust and attach a completed Certification of Trust (Form 1113).
Social Security #/Federal ID#
Social Security #/Federal ID#
INCIDENTAL DEATH BENEFIT
CHECK IF SAME BENEFICIARY(IES) AS IN SECTION II
FOR DATES OF RETIREMENT ON OR AFTER JANUARY 1, 2014
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.
If receiving workers' compensation benefits check here.
If disability is the result of a job-related injury, check this box and attach employer's first report of injury form.
(Certified copy of legal authorization required with signature other than applicant's)
(Required only when signed by mark)
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).
LAST NAME & SUFFIX (Jr., Sr., etc.)
Date of Birth (proof required)
Please contact PEBA's Customer Service 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.
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 6151S.