Applied for leave under sick leave bank
    (date leave begins):

Other (please explain):

On sick leave (date leave began):

EMPLOYER'S DISABILITY EMPLOYMENT STATUS REPORT 

To Be Completed by Applicant's Payroll/Benefits Officer

SC Public Employee Benefit Authority

South Carolina Retirement Systems 

Attention: Customer Services Annuity Claims 

PO Box 11960, Columbia, SC 29211-1960 

Annual  leave

Sick leave

4d.  Number of days of unused leave:
       (complete and proceed to Question 6a)

Annual  leave   

Sick leave        

4c.  Amount of lump-sum payments
       for unused leave

Telephone:

Date: 

Title:

Prepared by:

Signature: 

Please call SC Retirement Systems Customer Service with any questions: (800) 868-9002 (in state) or (803) 737-6800

Return completed form to the SC Retirement Systems (address above).

I hereby certify that to the best of my knowledge, the information above correctly reflects the records of the employing entity.

MM-DD-YYYY

MM-DD-YYYY

6b.  Is employee on leave without pay (not terminated) pending settlement
        of a Workers' Compensation claim?

6a.  Was this employee injured on the job?

5.  Employee's current payroll status (check one and indicate appropriate date):

On leave without pay (date leave began):

On annual leave (date leave began):

MM-DD-YYYY

4b.  Last day compensation was earned
       (including pay continuation, using
        annual and sick leave):

MM-DD-YYYY

MM-DD-YYYY

MM-DD-YYYY

4a.  Is this employee terminated?

(proceed to Question 4b)

*Attach letter explaining current duties in relation to normal work functions.

3c.  In what capacity is the employee currently working?

Leave without pay
(not terminated) (attach copy of Personnel Policy)

(skip to
Question 4a)

$

3b.  Is the employee performing all regular duties?

3a.  Is the employee currently working?

2.  Annual salary on date of disability:

1.  Is the position title shown above correct?  

Employer:

Social Security Number:

Employer Code:

Employee Name: 

The individual indicated below has applied for disability retirement  benefits.  Please complete the information on the remainder of this form, and return it to the address listed above as soon as possible.  Upon receipt of this completed form, the employee's application will be processed.

Form 6253
Revised 7/9/2012 

Print or type in black ink

Position Title:

3d.  Date member was placed

       in status shown at left:

$   

$