REQUEST FOR 48-MONTH RULE ELIGIBILITY
SC Public Employee Benefit Authority
Retirement Financial Services
202 Arbor Lake Drive
Columbia, SC 29223
1. Last Name & Suffix
SECTION I: EMPLOYEE INFORMATION (TO BE COMPLETED BY THE EMPLOYEE)
Print or type in black ink.
5. City
7. ZIP+4
8. Telephone Number
2. First/ Middle Name
6. State
11. Anticipated date for returning to active membership (generally the first day of a month):
4. Address
3. Social Security Number
9. Email Address
Please contact PEBA's Customer Service with any questions at 803.737.6800 or 888.260.9430, or www.peba.sc.gov.
12. Original date of retirement:
14. List qualifying covered employment after retirement (excluding TERI participation). If your monthly rate of compensation has changed while employed by a single employer, please separately list those periods of compensation below.
Member Signature
Date
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.
10. Applicable retirement plan for active membership:
13. Date returned to covered employment (excluding TERI participation):
Name of employer
Dates of employment
Monthly rate of compensation
Form 7101Revised 1/12/2024Page 1
Scripting must be enabled for this form to work correctly.