Applied for leave under sick leave bank
(date leave begins):
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
4d. Number of days of unused leave:
(complete and proceed to Question 6a)
4c. Amount of lump-sum payments
for unused leave
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.
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):
4b. Last day compensation was earned
(including pay continuation, using
annual and sick leave):
4a. Is this employee terminated?
*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)
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?
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.
Print or type in black ink
3d. Date member was placed
in status shown at left: