48-MONTH RULEREQUEST TO TERMINATE BENEFITS
AND RETURN TO ACTIVE SERVICE
SC Public Employee Benefit Authority
Retirement Financial Services
202 Arbor Lake Drive
Columbia, SC 29223
19. I hereby certify that the employee listed in Section I of this form is eligible for the retirement plan selected.
SECTION I: EMPLOYEE INFORMATION (TO BE COMPLETED BY THE EMPLOYEE)
Form 7100
Revised 1/12/2024
Page 1
Print or type in black ink.
Please read the instructions on Page 2 before completing this form.
SECTION II: ELECTION TO RETURN TO ACTIVE MEMBERSHIP (COMPLETED BY EMPLOYEE)
15. Please indicate if you are the employee's
primary or secondary employer.
18. Employee's Annual Salary
17. Employee's Position Title
16. Restored to Active Status
10. Applicable retirement plan for active membership
3. Social Security Number
Please contact PEBA's Customer Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
11. Date returning to active membership (First day of the month; cannot be retroactive)
12. By executing this form, I am electing to cancel my retirement benefits from SCRS and/or PORS and become an active member of the retirement system indicated above as of the date shown. I understand that by electing to return to active membership in the retirement systems, I am voiding my prior retirement election, including all payment option elections and beneficiary designations made in connection with that retirement.
I further understand that my eligibility to make this election is pursuant to, and subject to the provisions of, Sections 9-1-1590 and/or 9-11-90(3) of the South Carolina Code of Laws, as applicable.
I hereby certify that I have read and understand the information provided on this form, including the information on the reverse side, and I agree to the terms stated.
SECTION III: EMPLOYER INFORMATION (COMPLETED BY THE EMPLOYER)
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.
Original date of retirement:
Date returned to work as working retiree:
Date monthly benefit to be terminated:
SECTION IV: OFFICE USE ONLY (DO NOT COMPLETE)