CSS2HTML: WEB6500.XDP

Form 6500
Revised 12/3/2015
Page 1


Print or type in
black ink and sign
in blue ink.

FOR OFFICE USE ONLY

EMPLOYER ELIGIBILITY DETERMINATION REQUEST

(for participation in the Retirement Systems)

 

SC Public Employee Benefit Authority

ATTN: LEGAL DEPARTMENT

202 Arbor Lake Drive

Columbia, SC 29223

7. City

11. City

5. Number of Employees

9. ZIP+4

13. ZIP+4

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)

8. State

12. State

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

(IF REVIEWED, PLEASE INITIAL) ____________

19. Employer's governing board consists of

20. Are these board members elected or appointed?

21. If either elected or appointed, by whom or which authority?

22. Enabling Authority

23. Does employer currently have a pension plan in place?

(59-40-130)

2. Form of Government of Public Entity Type:

24. Are your employees covered under the Social Security Act?

6. Mailing Address

10. Location
      (Street)
      Address

14. Employer Phone Number

15. Employer Fax Number

16. Employer Email Address

18. Does employer close for lunch?

(DAYS AND HOURS OF THE WEEK EMPLOYER IS OPEN FOR BUSINESS)

(PLEASE ATTACH STATUTE OR ORDINANCE CREATING ENTITY, ARTICLES OF INCORPORATION, AND BYLAWS, IF APPLICABLE)

17. Business Hours