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MEMBER'S SIGNATURE DATE

WITNESS DATE

Form 6151S
Revised 4/29/2021
Page 1

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

SCRS

Date first eligible for

disability retirement

Section IV

Section II*

PERSONAL INFORMATION

TYPE OR PRINT IN BLUE INK

Current/Former Employer(s)

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).

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 #

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

Social Security #

2. Name of Beneficiary

Date of Birth

Social Security #

2. Name of Beneficiary

Date of Birth

Relationship (Check one)

Sex

Date of Birth

3. Name of Beneficiary

Your Position Title

OFFICE USE ONLY

FOR DATES OF RETIREMENT ON OR AFTER JANUARY 1, 2014

Section V

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

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.

Correlated

Check
One

(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).

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 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.