Form 6500Revised 6/15/2021Page 1Print or type in black ink and signin blue ink.
FOR OFFICE USE ONLY
SC Public Employee Benefit Authority
ATTN: LEGAL DEPARTMENT
202 Arbor Lake Drive
Columbia, SC 29223
5. Number of Employees
SECTION I: EMPLOYER INFORMATION
SECTION II: GOVERNING BOARD INFORMATION
SECTION III: CURRENT PENSION PLAN INFORMATION
4. State Tax ID
3. Federal Tax ID
(DEFINE BUSINESS PURPOSE)
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.
1. Legal Name of Employer
17. Employer's governing board consists of
18. Are these board members elected or appointed?
19. If either elected or appointed, by whom or which authority?
20. Enabling Authority
21. Does employer currently have a pension plan in place?
2. Form of Government of Public Entity Type:
22. Are your employees covered under the Social Security Act?
6. Mailing Address
10. Location Street Address
14. Employer Phone Number
15. Employer Email Address
(PLEASE ATTACH STATUTE OR ORDINANCE CREATING ENTITY, ARTICLES OF INCORPORATION, AND BYLAWS, IF APPLICABLE)
EMPLOYER ELIGIBILITY DETERMINATION REQUEST
(for participation in the Retirement Systems)
23. Do you participate in PEBA insurance?
24. Do you participate in SC Deferred Compensation?
If yes, code:
If yes, group number:
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