Number

Number

Title

Name

IN WITNESS WHEREOF, I have hereunto set my hand and the authority of the aforesaid entity.

members voted in favor of the above RESOLUTION.

duly elected/appointed members and that, as stated above,

hereby certify that the aforesaid body consists of

of the aforesaid entity, do

I,

Signatures of Governing Body (a majority must sign):

Year

Day

Month

day of

IN WITNESS WHEREOF, we have hereunto set our hands and authority this

Title - i.e., Town Clerk, Director, etc.

Date (Jul.1, Oct.1, Jan.1 or Apr.1)

This coverage is to become effective

necessary steps for application in and to the Police Officers Retirement System; and is hereby further authorized, empowered and ordered to make the required deductions from the gross salary of employees electing to, or required to, become members of the Police Officers Retirement System and to transmit such deductions to the Police Officers Retirement System together with the required Employer Contributions, under the provisions of the Act and Rules and Regulations of the Board, as may be amended from time to time.

to take  the 

given to the 

That the governing body does by this Resolution make an application to join the Police Officers Retirement System, as an employer, under the provisions of the 1976 Code of Laws of South Carolina, and authority  is here

THEREFORE, it being in the best interests of the employees of the aforementioned entity, now be it ordained by this governing body, in regular meeting duly assembled:

State of South Carolina, approves the inclusion of the employees of the aforesaid entity in the Police Officers Retirement System, under provisions ?9-11-10 through  ?9-11-525 of the 1976 Code of Laws of South Carolina and agrees to comply with the requirements of said Act and Rules and Regulations of the Board, as may be amended from time to time.

RESOLVED, that the

of 

, the following resolution was offered:

, on

Location

, South Carolina, held at

County of 

Legal Name of Entity

of 

Governing Body

At a meeting of the 

See instructions on Page 2.

Employer Resolution and Application

SC Public Employee Benefit Authority

Police Officers Retirement System

202 Arbor Lake Drive, Columbia, SC 29223

EmployerServices@peba.sc.gov

Form 6501P
Revised 6/15/2021
Page 1

Certification

Governing Body

Legal Name of Entity

County

Date (MM-DD-YYYY)

Date (MM-DD-YYYYY)

Signature